Minilaparotomy: a minimally invasive alternative for major gynecologic abdominal surgery

Minilaparotomy, Cyfra21-1, and Other Predicting Factors for Suboptimal Cytoreductive Surgery in Advanced Epithelial Ovarian Cancer: A Pilot Study

BACKGROUND

Currently, there is no reliable method to predict the result of the primary cytoreduction to decide whether to go on primary cytoreductive surgery or receive neoadjuvant chemotherapy. This study aimed to identify candidate predicting factors from clinical data, serum biomarkers, CT/MRI imaging, and minilaparotomy for suboptimal cytoreduction in women with advanced epithelial ovarian cancer.

METHODS

Women who were clinically suspicious of advanced-stage epithelial ovarian, fallopian tube, and peritoneal cancer undergoing primary cytoreductive surgery were recruited. Clinical data, abdominopelvic CT/MRI, and serum biomarkers, including CA125, HE4, and Cyfra21-1, were collected preoperatively. At the start of the surgery, a minilaparotomy incision was made, the peritoneal cavity was assessed, and the operating surgeons gave the impression of whether the optimal cytoreductive surgery would be attainable. Subsequently, the incision was extended as necessary, and the standard cytoreductive surgery was attempted. After the procedure completion, the surgical outcome (optimal vs. suboptimal cytoreduction) and other operative outcomes were recorded. The association between the potential predicting factors and the surgical outcome was examined.

RESULTS

Fourteen patients were included in this pilot study. Twelve patients were diagnosed with primary ovarian or fallopian tube cancer, while two had ovarian metastasis from colorectal cancer. The optimal cytoreduction was achieved in eight women. After minilaparotomy, the surgeons could predict suboptimal surgery correctly in five out of six cases (OR: 24.12, 95%CI: 2.34-Inf., p<0.01). Moreover, no patient with the finding of rectosigmoid invasion from CT had optimal surgery (OR: 12.96, 95%CI: 1.26-Inf., p=0.03). Lastly, increased serum cyfra21-1(>8 ng/mL) and HE4 (>83 pmol/L) were significantly associated with suboptimal cytoreduction, with OR: 35.00, 95%CI: 1.74-702.99, p=0.02 and OR: 15.00, 95%CI: 1.03-218.30, p=0.05, respectively.

CONCLUSION

The finding of rectosigmoid invasion from abdominal CT, increased serum cyfra21-1 and HE4, and the initial minilaparotomy impression were potentially associated with suboptimal cytoreduction.

No 371 - Le morcellement durant la chirurgie gynécologique: Son utilisation, ses complications et les risques liés à la présence de tumeurs malignes insoupçonnées

OBJECTIF

La présente directive clinique conseille les gynécologues quant au recours au morcellement tissulaire pendant une chirurgie gynécologique. RéSULTATS: Le morcellement effectué au cours d'une chirurgie gynécologique peut permettre l'ablation de masses utérines volumineuses, offrant ainsi aux femmes une solution chirurgicale à effraction minimale. Les conséquences oncologiques indésirables du morcellement tissulaire devraient être atténuées par l'amélioration de la sélection des patientes, la tenue d'examens préopératoires et l'adoption de techniques novatrices réduisant au minimum la dispersion tissulaire. ÉVIDENCE: La littérature publiée a été récupérée au moyen de recherches menées dans PubMed et Medline au printemps 2014 à l'aide d'une terminologie contrôlée (« leiomyosarcoma », « uterine neoplasm », « uterine myomectomy », « hysterectomy ») et de mots-clés (« leiomyoma », « endometrial cancer », « uterine sarcoma », « leiomyosarcoma », « morcellation »). Les résultats retenus provenaient de revues systématiques, d'essais cliniques randomisés, d'essais cliniques contrôlés et d'études observationnelles de langue anglaise ou française. Aucune restriction de date n'a été imposée. Les recherches ont été refaites régulièrement, et les résultats ont été incorporés à la directive clinique jusqu'en juillet 2017. Nous avons également tenu compte de la littérature grise (non publiée) trouvée sur les sites Web d'organismes d'évaluation des technologies de la santé et d'autres organismes liés aux technologies de la santé, dans des collections de directives cliniques et dans des registres d'essais cliniques, et obtenue auprès d'associations nationales et internationales de médecins spécialistes.

VALEURS

La qualité des données probantes a été évaluée en fonction des critères décrits dans le rapport du Groupe d'étude canadien sur les soins de santé préventifs. AVANTAGES, INCONVéNIENTS ET COûTS: Les gynécologues offrent aux femmes une chirurgie à effraction minimale pouvant comprendre le recours à un morcellateur électromécanique pour faciliter le retrait des tissus. Les femmes devraient être informées que l'utilisation d'un morcellateur en présence de tumeurs utérines (sarcomes, tumeurs endométriales), cervicales ou tubo-ovariennes jusque-là insoupçonnées est associée à un risque accru de dissémination. Le morcellement tissulaire devrait être précédé d'une évaluation complète, d'une sélection appropriée des patientes et de l'obtention du consentement éclairé de ces dernières, et devrait être effectué par des chirurgiens ayant une formation adéquate en matière de pratiques de morcellement tissulaire sûres. DéCLARATIONS SOMMAIRES: RECOMMANDATIONS.

No. 371-Morcellation During Gynaecologic Surgery: Its Uses, Complications, and Risks of Unsuspected Malignancy

OBJECTIVE

This guideline provides guidance to gynaecologists regarding the use of tissue morcellation in gynaecologic surgery.

OUTCOMES

Morcellation may be used in gynaecologic surgery to allow removal of large uterine specimens, thus providing women with a minimally invasive surgical option. Adverse oncologic outcomes of tissue morcellation should be mitigated through improved patient selection, preoperative investigations, and novel techniques that minimize tissue dispersion.

EVIDENCE

Published literature was retrieved through searches of PubMed and Medline in the spring of 2014 using appropriate controlled vocabulary (leiomyosarcoma, uterine neoplasm, uterine myomectomy, hysterectomy) and key words (leiomyoma, endometrial cancer, uterine sarcoma, leiomyosarcoma, and morcellation). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date limits, but results were limited to English or French language materials. Searches were updated on a regular basis and incorporated in the guideline to July 2017. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The quality of evidence in this document was rated using the criteria described in the report of the Canadian Task Force on Preventive Health Care.

BENEFITS, HARMS, AND COSTS

Gynaecologists offer women minimally invasive surgery, and this may involve tissue morcellation and the use of a power morcellator for specimen retrieval. Women should be counselled that in the case of unexpected uterine (sarcoma, endometrial), cervical, and/or tubo-ovarian cancer, the use of a morcellator is associated with increased risk of tumour dissemination. Tissue morcellation should be performed only after complete investigation, appropriate patient selection, and informed consent and by surgeons with appropriate training in the safe practices of tissue morcellation.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Single layer suturing in intracapsular myomectomy of intramural myomas is sufficient for a normal wound healing

STUDY OBJECTIVE

To evaluate surgical outcomes of intracapsular single-layer myomectomy in terms of efficacy and safety as well as examine potential alterations based on kind of surgical approach.

METHODS

A prospective observational study was performed between January 2010 and December 2018. Women in reproductive age, affected by intramural or subserous myomas (FIGO type 3-6) of 4-14 cm diameter were enrolled. Primary outcomes included initial and final uterine incision length, time to wound healing and uterine rupture in subsequent pregnancies. Furthermore, a sub-analysis was also performed regarding surgical approach, namely laparoscopical or laparoscopically-assisted myomectomy, in order to confirm whether overall observations are similar for both potential surgical approaches.

RESULTS

There were finally 273 patients included in the present study. Overall mean uterine incision was initially 3.1 cm and was shortened to 2.2 cm at the end of operation, indicating a reduction of 29.1 %. Mean estimated blood loss was 154.2 mL and mean operative time was 82.1 min. No severe intraoperative and postoperative complications were presented. 121 of the studied women had pregnancy 3-36 months after myomectomy, without reporting any uterine rupture. When comparing LIM vs. LAIM, all outcomes were also favorable in the total of patients.

CONCLUSION

Intracapsular myomectomy either by LIM or LAIM is a safe and attractive alternative to abdominal myomectomy in setting of premenopausal patients with myomas up to 14 cm. A single-layer continuous suturing in intracapsular myomectomies is enough for a successful wound healing.

Feasibility and Compatibility of Minilaparotomy Hysterectomy in a Low-Resource Setting

Introduction

Minilaparotomy hysterectomy (MLH) relies on the simplicity of the traditional open technique of abdominal hysterectomy, imparts cosmesis and faster recovery of laparoscopic hysterectomy yet avoids the long learning curve and cost of expensive setup and instrumentation associated with the minimally invasive approaches, namely, laparoscopy and robotics. In the present study, we tried to ascertain whether the results obtained with MLH can be compared to LAVH in terms of its feasibility, intraoperative variables, and complications. The null hypothesis was that both MLH and LAVH are comparable techniques; thus, where cost and surgeon's experience are the confining issues, patients can be reassured that MLH gives comparable results.

Materials and Methods

This was a prospective observational study done over a period of two years at a university teaching hospital. A total of 65 patients were recruited, but only 52 (MLH: 27; LAVH: 25) could be included in final analysis. All surgeries were performed by one of the two gynecologists with almost equal surgical competence, and outcomes were compared.

Results

MLH is a feasible option for benign gynecological pathologies as none of the patients required increase in the initial incision (4–6 cm). MLH could be done for larger uteri (MLH: 501.30 ± 327.96 g versus LAVH: 216.60 ± 160.01 g; p < 0.001), in shorter duration (MLH: 115.00 ± 21.43 min versus LAVH 172.00 ± 27.91 min; p < 0.001), with comparable blood loss (MLH: 354.63 ±227.96 ml; LAVH: 402.40 ± 224.02 ml; p=0.334), without serious complications when compared to LAVH.

Conclusion

The technique of MLH should be mastered and encouraged to be used in low-resource setting to get results comparable to laparoscopic surgery. This trial is registered with NCT03548831.

Minilaparotomy Hysterectomy as a Suitable Choice of Hysterectomy for Large Myoma Uteri: Literature Review

The objective of this paper is to propose minilaparotomy hysterectomy as the suitable choice for large uterus on the basis of our experienced case of performed minilaparotomy hysterectomy to 4,500 g myoma uteri and review published cases about this clinical condition. We presented a 44-year-old woman (gravida 0, virgin) who consulted our hospital because of the chief complaints of abnormal genital bleeding and hypermenorrhea. Transabdominal ultrasonography revealed that abdominal solid tumor reached over the navel. Her tumor was an indication of surgery; to do minilaparotomy hysterectomy with laparoscope was decided because her informed consent was obtained. A 6 cm transverse incision (Maylard incision) was made to the skin above the pubic hairline. At the end of surgery, the length of abdominal wound was 8.5 cm, operating time was 128 min, weight of resected myoma uteri was 4,500 g, and intraoperative blood loss was 895 mL. Blood transfusion was not done; postsurgical course was not a problem without anemia. We propose that a large uterine case in which it is difficult to perform vaginal or laparoscopic hysterectomy should be considered in order to select minilaparotomy hysterectomy up to around 5 kg weight of uterus, and the length of skin incision in minilaparotomy hysterectomy is necessarily <9 cm particularly in large uterus.

Technical update on tissue morcellation during gynaecologic surgery: its uses, complications, and risks of unsuspected malignancy

OBJECTIVE

To review the use of tissue morcellation in minimally invasive gynaecological surgery.

OUTCOMES

Morcellation may be used in gynaecological surgery to allow removal of large uterine specimens, providing women with a minimally invasive surgical option. Adverse oncologic outcomes of tissue morcellation should be mitigated through improved patient selection, preoperative investigations, and novel techniques that minimize tissue dispersion.

EVIDENCE

Published literature was retrieved through searches of PubMed and Medline in the spring of 2014 using appropriate controlled vocabulary (leiomyomsarcoma, uterine neoplasm, uterine myomectomy, hysterectomy) and key words (leiomyoma, endometrial cancer, uterine sarcoma, leiomyosarcoma, morcellation, and MRI). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date limits but results were limited to English or French language materials. Searches were updated on a regular basis and incorporated in the guideline to August 2014. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The quality of evidence in this document was rated using the criteria described in the report of the Canadian Task Force on Preventive Health Care. (Table 1) BENEFITS, HARMS, AND COSTS: Gynaecologists may offer women minimally invasive surgery and this may involve tissue morcellation and the use of a power morcellator for specimen retrieval. Women should be counselled that in the case of unexpected uterine sarcoma or endometrial cancer, the use of a morcellator is associated with increased risk of tumour dissemination. Appropriate training and safe practices should be in place before offering tissue morcellation. SUMMARY STATEMENTS: 1. Uterine sarcomas may be difficult to diagnose preoperatively. The risk of an unexpected uterine sarcoma following surgery for presumed benign uterine leiomyoma is approximately 1 in 350, and the rate of leiomyosarcoma is 1 in 500. (II-2) This risk increases with age. (II-2) 2. An unexpected uterine sarcoma treated by primary surgery involving tumour disruption, including morcellation of the tumour, has the potential for intra-abdominal tumour-spread and a worse prognosis. (II-2) 3. Uterus-sparing surgery remains a safe option for patients with symptomatic leiomyomas who desire future fertility. (II-1) RECOMMENDATIONS: 1. Techniques for morcellation of a uterine specimen vary, and physicians should consider employing techniques that minimize specimen disruption and intra-abdominal spread. (III-C) 2. Each patient presenting with uterine leiomyoma should be assessed for the possible presence of malignancy, based on her risk factors and preoperative imaging, although the value of these is limited. (III-C) 3. Preoperative endometrial biopsy and cervical assessment to avoid morcellation of potentially detectable malignant and premalignant conditions is recommended. (II-2A) 4. Hereditary cancer syndromes that increase the risk of uterine malignancy should be considered a contraindication to uncontained uterine morcellation. (III-C) 5. Uterine morcellation is contraindicated in women with established or suspected cancer. (II-2A) If there is a high index of suspicion of a uterine sarcoma prior to surgery, patients should be advised to proceed with a total abdominal hysterectomy, bilateral salpingectomy, and possible oophorectomy. (II-2C) A gynaecologic oncology consultation should be obtained. 6. Tissue morcellation techniques require appropriate training and experience. Safe practice initiatives surrounding morcellation technique and the use of equipment should be implemented at the local level. (II-3B) 7. Morcellation is an acceptable option for retrieval of benign uterine specimens and may facilitate a minimally invasive surgical approach, which is associated with decreased perioperative risks. Each patient should be counselled about the possible risks associated with the use of morcellation, including the risks associated with underlying malignancy. (III-C).

Minilaparotomy vs laparoscopic hysterectomy for benign gynaecological diseases

Hysterectomy is the most frequent gynaecological procedure carried out with either conventional (abdominal) or minimally invasive surgery (MIS). Despite the advantage of MIS compared with the conventional procedure, it requires extensive training and a long learning curve. Minilaparotomy hysterectomy is an alternative approach that needs no sophisticated and expensive equipment or training. The objective of this study was to compare the perioperative outcomes between minilaparotomy hysterectomy (MH) and laparoscopic hysterectomy (LH) in patients with benign gynaecological diseases. A significantly shorter operative time was obtained in MH. There was no significant difference in blood loss and perioperative complications. However, a higher intraoperative complication (two bladder injuries and one major blood loss) were observed in the LH. Early postoperative VAS pain scores and recovery time were insignificantly different between both groups. Overall patient satisfaction levels and satisfaction scores were found to be similar in both groups, without significant difference.

Hysterectomy through minilaparotomy for benign gynaecological conditions: a valid option

OBJECTIVE

Efforts are continuously being made for surgery to be less invasive with a minimal access approach. This article reports our experience with minilaparotomy hysterectomy in patients with benign gynecological disease or preinvasive pathology.

MATERIAL AND METHODS

A prospective study to analyse the outcome and per-operative and post-operative complications was conducted in 69 patients undergoing hysterectomy by the minilaparotomy approach through 4-5cm Pfannenstiel incision.

RESULTS

The mean operating time and postoperative hospital stay were 41.3 min and 3.1 days, respectively. Composite morbidity was encountered in 12 women (17.4%) with no major complications or mortality. None of the patients had an estimated blood loss over 500ml.

CONCLUSION

Minilaparotomy hysterectomy in benign gynecological disease provides an appealing, effective, expeditious, minimal access and cost-effective option/alternative to the traditional abdominal hysterectomy. It obviates the need for any additional expensive equipment and above all improves upon the per-operative and post-operative outcomes without compromising, whatsoever, the quality of surgery.

Minilaparotomy-assisted LAVH for a very large fibroid

We present the case report of a minilaparotomy-assisted LAVH carried out for the largest uterine myoma ever reported, with size equivalent to a full-term gestation.