[DIFFICULTIES IN DISSECTION OF URINARY BLADDER IN TOTAL LAPAROSCOPIC HYSTERECTOMY.]

The dissection of urinary bladder is a crucial phase of the laparoscopic operation of hysterectomy. The latter dissection may become even more difficult in the context of history of operative interventions as cesarean section or cervical conization, presence of cervical or isthmic myomatous nodes, as well as upon a bad operative technique. The obeying of some basic principles (knowledge of pelvic anatomy and topographic interrelations; considering of present risk factors; intraoperative screening for complications and their early treatment) results in the optimal performance of laparoscopic hysterectomy.

[Areas of risk for ureteral lesion during radical hysterectomy].

INTRODUCTION: The close interrelations of the pelvic ureter with surrounding structures and organs are a prerequisite for complications during surgical interventions in the lesser pelvis. OBJECTIVE: Exploration and visualization of the areas of risk for lesion of pelvic ureter during minimally invasive radical hysterectomy. RESULTS: Based on our observations and the available literature, we identified the following areas and steps of the radical hysterectomy as risky: at the entrance in the lesser pelvis, upon ligation of the infundibulopelvic ligament; incision of the back leaf of broad ligament of the uterus; dissection of the pararectal space; ligation of the uterine artery; dissection of the fourth space and transection of the vesicouterine ligaments; transection of the sacrouterine ligaments; incision of the anterior vaginal wall. We registered one uretero-vaginal fistula in a total of 133 patients on the eighth postoperative day. The lesion was identified in area of the distal portion of ureter. CONCLUSION: Knowledge about the ureter location, its interrelations with surrounding structures, and its blood supply, combined with capable surgical techniques, would contribute to reduction of the incidence of complications.

[Significance of umbilical position for the operative approach in minimally invasive hysterectomy].

UNLABELLED: Umbilicus is a main reference point for insufflation of CO2 in the peritoneal cavity. AIM: Proposing of individualization of trocar placement, based on the type of surgery and the anthropometric parameters of patient. MATERIAL AND METHODS: Several distances on the anterior abdominal wall were measured in 61 patients of the Oncogynecology Clinic - Pleven with a view to determination of the location of umbilicus. RESULTS AND DISCUSSION: Umbilicus is a median structure in horizontal and vertical line in patients of underweight, normal weight, and overweight, and could be used as a main reference point for allocation of ports for robotic and laparoscopic radical hysterectomy. The distance between xiphoid process and umbilicus, and the waist circumference are increased in obese patients, which facilitates the trocar placement for robotic surgery. However the access for laparoscopic hysterectomy is more difficult in obese patients, due to allocation of ports in the lower portion of anterior abdominal wall, where more fat is accumulated. CONCLUSION: Providing of "convenient" access is a crucial step for performing of elective endoscopic surgical intervention.

[Complications in gynecologic laparoscopic surgery--retrospective and prospective study].

Laparoscopic surgery is a surgical approach with proven advantages in the contemporary treatment of gynaecological diseases. It is applied with proven results in oncologic patients in order to respect certain rules. Mini-invasive approach has less complication and therefore is widely recommended. In this respect, the constantly increasing interest in this surgery and additional training and education. Risk factors must be taken into consideration and patients should be informed about possible complications during surgery.

Intraductal aspiration cytology and galactography for nipple discharge.

The objective of this study was to assess the diagnostic value of preoperative cytology and galactography in women with nipple discharge using a simple intraductal aspiration method. From May 1997 to February 2002, 172 patients with unilateral, spontaneous nipple discharge without palpable masses underwent intraductal aspiration cytology followed by galactography. Major duct excision was performed in 133 of 155 successful cases. Pathological findings showed solitary papilloma in 65 cases, breast cancer in 16 cases, fibrocystic disease in 17 cases, papillomatosis in 12 cases, ductal hyperplasia in 11 cases, and finally, duct ectasia in 12 cases. Our results showed sensitivity of 75.0% and 68.8%, specificity of 86.3% and 62.4%, and overall accuracy of 85.1% and 63.2%, respectively, for cytological analysis and galactography. This suggests that the intraductal aspiration method for preoperative cytology and galactography is a minimally invasive and well-tolerated procedure that seems to be useful in differentiating between benign and malignant lesions in patients with unilateral, spontaneous nipple discharge.

Intraoperative sentinel lymph node examination by imprint cytology during breast surgery.

BACKGROUND: Sentinel lymph nodes (SLNs) predict the axillary status and may allow lymphadenectomy on a selective basis. The aim of this study was to assess the accuracy of intraoperative imprint cytology (IC) analysis of sentinel nodes in patients with early breast cancer. METHODS: A total of 128 SLNs from 87 cases that had been identified with Patent blue dye were bisected for hematoxylin and eosin stained touch preparations. Intraoperative evaluation of sentinel node involvement by IC was compared with the final histopathological results of permanent sections. Tumour-negative nodes in standard paraffin sections were further studied using an anticytokeratin antibody (CK-IHC). RESULTS: Thirty-six of all SLNs contained metastases in paraffin sections, of which 32 were detected by IC procedure (sensitivity 88.8%). Three sentinel nodes were tumour-positive on imprint cytology and tumour-negative on stained paraffin sections. Comparison of the results of the imprints with the final histology (H&E and CK-IHC) showed a sensitivity of 83.3% and a negative predictive value of 92.5%. The specificity and positive predictive value were 100%. CONCLUSION: Touch imprint cytology is a simple and quick method of intraoperative screening of SLNs for the presence of metastases in patients with breast cancer. Results may be improved by an appropriate enlargement of the surface sampled and the use of rapid CK-IHC on the touch preparations.