Laparoscopic Ovarian Dermoid Cystectomy in 10 Steps.

STUDY OBJECTIVE: Laparoscopic cystectomy for ovarian teratomas has the advantages of a minimally invasive approach [1]. The standardization and description of the technique are the main objectives of this video (Video 1). We described the surgery in 10 steps [2], which could help make this procedure easier and safer. DESIGN: A step-by-step video demonstration of the technique. SETTING: A French university tertiary care hospital. PATIENTS: Patients with ovarian teratomas with indication for laparoscopic cystectomy [3]. The local institutional review board ruled that approval was not required for this video article because the video describes a technique and does not report a clinical case. INTERVENTIONS: Standardized laparoscopic cystectomies were recorded to realize the video. MEASUREMENTS AND MAIN RESULTS: This video presents a systematic approach to cystectomy for teratoma clearly divided into 10 steps: (1) planning of the surgery, (2) ergonomy and materials, (3) exploration and cytology, (4) prevention of peritoneal spillage [4], (5) mobilization of the ovary, (6) incision of the ovary, (7) dissection, (8) hemostasis, (9) exteriorization of the cyst, and (10) washing and exploration. CONCLUSION: Standardization of laparoscopic cystectomy for ovarian teratoma could make this procedure easier and safer to perform. The 10 steps presented help to perform each part of the surgery in a logical sequence, making the procedure ergonomic and easier to adopt and learn. Moreover, the standardization of the surgical techniques could reduce the learning curve.

Indocyanine green in gynecologic surgery: Where do we stand? A literature review and meta-analysis.

The main objective of this study was to review and perform a meta-analysis of current literature on the use of indocyanine green for sentinel lymph node detection in pelvic gynecologic cancer. We included all studies focusing on indications and procedures associated with the use of ICG in gynecologic surgery and available on the Medline and Pubmed database. For the meta-analysis, random effect models were used for estimation of the 95 % detection rate and 95 % confidence interval, and stratified analyses by cancer type, concentration and localization of injection were performed. A total of 147 articles were included, of which 91 were studied in a meta-analysis. Results concerning detection rate by indocyanine green injection site were found to be 95.1 % and 97.3 % respectively for intracervical injection in 2 or 4 quadrants, and 77.0 % and 94.8 % for hysteroscopic and intradermal injection respectively. Results concerning detection rate by cancer type were 95.8 %, 95.2 %, 94.7 % and 95.7 % respectively for cervical, endometrial, vulvar and endometrial/cervical cancers. Finally, the results concerning detection rate by indocyanine green concentration were 91.2 %, 95.7 %, 96.7 % and 97.7 % for concentrations of <1.25 mg/ml, 1.25 mg/ml, 2.5 mg/ml and 5 mg/ml respectively. In conclusion, indocyanine green is shown to allow highlighting of sentinel lymph nodes with good reliability with an overall indocyanine green detection rate of 95.5 %. Our literature review revealed that indocyanine green feasibility has also been demonstrated in several surgical contexts, notably for reconstructive surgery and detection of endometriosis.

Indocyanine green in deep infiltrating endometriosis: a preliminary feasibility study to examine vascularization after rectal shaving.

OBJECTIVE: To evaluate the feasibility of using indocyanine green (ICG) to estimate the vascularization of the resected zone during a laparoscopic rectal shaving. DESIGN: Indocyanine green can highlight blood vascularization when injected intravenously. There is no relevant, objective, intraoperative method to assess the vascularity of the resected zone during a laparoscopic rectal shaving for deep infiltrating endometriosis (DIE) to prevent fistula. We conducted a registered clinical trial examining the feasibility of the use of ICG to evaluate the bowel vascularization after endometriosis rectal shaving (Institutional Review Board number 2016-002773-35). SETTING: Tertiary university hospital. PATIENT(S): Twenty-one patients underwent laparoscopic surgery for DIE with a rectal shaving. INTERVENTION(S): Patients undergoing laparoscopic surgery for DIE received ICG intravenously at the end of the endometriosis resection. MAIN OUTCOME MEASURE(S): The main evaluation criteria was the fluorescence degree in the operated rectal area and in the vaginal suture. We used a visual assessment with a Likert-type scale from 0 to 4 (0 = no fluorescence; 4 = very good fluorescence). RESULT(S): No adverse reaction was recorded. Most of the patients (81%) showed very good fluorescence levels at the rectal shaving area. The protocol did not increase the operating time. In one patient we changed the surgical strategy making two stitches to bring the rectal muscularis closer together, which improved the degree of fluorescence. There was no case of digestive fistula. CONCLUSION: Indocyanine green fluorescent imaging is feasible in endometriosis surgery and may be considered as a potential candidate to further enhance patient safety in endometriosis bowel surgery. CLINICAL TRIAL REGISTRATION NUMBER: NCT03080558.

Use of indocyanine green in endometriosis surgery.

OBJECTIVE: To report and visually demonstrate the feasibility of using indocyanine green (ICG) in endometriosis surgery and to discuss potential benefits. DESIGN: ICG fluorescent imaging has been validated to assess tissue perfusion with clinical use in many medical fields, including gynecology and digestive surgery, but has not described in endometriosis surgery for bowel assessment. To our knowledge, there is no validated, objective, intraoperative method to assess the vascularity of the operated bowel in endometriosis surgery, a potentially good indicator for postoperative fistula formation. Our center is conducting a registered clinical trial examining the use of ICG to evaluate the bowel vascularization after endometriosis rectal shaving surgery, and the potential role in reducing fistula rates (Institutional Review Board no 2016-002773-35). SETTING: Tertiary university hospital. PATIENT(S): Three patients undergoing laparoscopic surgery for deep infiltrating endometriosis (DIE) with the use of a rectal shaving procedure. INTERVENTIONS(S): Patients undergoing laparoscopic surgery for DIE with a rectal shaving procedure were injected with ICG intravenously at the end of endometriosis resection. MAIN OUTCOME MEASURES: Visual assessment of the rectal shaving area was assessed as fluoresced or not with the use of a Likert-type scale (0 = no fluorescence; 4 = very good fluorescence). RESULT(S): After ICG injection, all three patients have showed very good fluorescence levels at the rectal shaving area with no adverse reactions. Other uses of ICG are demonstrated throughout the video (vaginal cuff, ureter, and ovary assessment). CONCLUSION(S): ICG fluorescent imaging is feasible in endometriosis surgery, and there is an ongoing trial to determine if its use reduces postoperative fistula formation. CLINICAL TRIAL REGISTRATION NUMBER: NCT03080558.