Ovarian cancer laparoscopic hysterectomy and staging in a patient with history of intraperitoneal renal transplant.

OBJECTIVE: Ovarian cancer laparoscopic staging of patient with intraperitoneal renal transplant. METHODS: 43-year-old female with intra-peritoneal renal transplant was referred status post laparoscopic bilateral ovarian cystectomies. The pathology report revealed serous adenocarcinoma with clear cell and papillary features of ovaries and endometrium. She was asymptomatic with benign examination. PET/CT of chest/abdomen/pelvis showed area of metabolic activity in left ovary and right common iliac pelvic lymph nodes. RESULTS: During laparoscopic staging [1], the intraperitoneal kidney transplant was firmly adhered to the uterus, right pelvic sidewall and adnexa. Right pelvic lymph node debulking was performed but not paraaortic lymph node dissection because of increased morbidity of this case. The final pathology showed ovarian serous adenocarcinoma with clear cell features, without involvement of endometrium, negative lymph nodes and peritoneal washings. We believe that the intrauterine pathological finding during the first surgery was "drop lesion" from the ovary to the uterine cavity. Thus, the final stage assigned was IC1, secondary to ovarian cyst rupture at the initial surgery. She received six cycles of intravenous Carboplatin and Taxol. There is no evidence of recurrence in nine-month follow up. CONCLUSION: The incidence of malignancies is increasing in cases of renal transplant secondary to the age of patients and the immunosuppressive therapy [2,3]. Laparoscopic surgical treatment for gynecologic malignancies can be challenging due to location of transplanted kidney in the pelvis [4]. We present a rare case of laparoscopic ovarian cancer staging with intraperitoneal renal transplant, which can be safely performed in hands of a skilled laparoscopic surgeon.

Comparison of perioperative outcomes and complication rates between conventional versus robotic-assisted laparoscopy in the evaluation and management of early, advanced, and recurrent stage ovarian, fallopian tube, and primary peritoneal cancer.

OBJECTIVE: The objective of this study was to examine perioperative outcomes, including complication rates, of conventional laparoscopy (CL) versus robotic-assisted laparoscopy (RALS) in the evaluation and management of early, advanced, and recurrent ovarian, fallopian tube, and peritoneal cancer. METHODS: This is a retrospective analysis of a prospectively maintained database of surgery performed from July 2008 to December 2012. Sixty-three women had 83 surgeries performed; 22 surgeries for early-stage disease (International Federation of Gynecology and Obstetrics stage I) and 61 for advanced and/or recurrent disease. RESULTS: Of the 22 for early stage, 10 were CL, 9 were RALS, and 3 were laparoscopy converted to laparotomy (LP). There was no significant difference between CL and RALS in estimated blood loss (EBL, P = 0.27) or length of stay (LOS, P = 0.43); however, both had significantly less EBL (P = 0.03 and 0.03, respectively) and LOS (P = 0.03 and 0.03) than LP. There was no difference in OR time among the groups (P = 0.79). One patient (33%) had an intraoperative complication in LP. One patient (10%) had a postoperative complication in CL, 2 (22%) in RALS, and 1 (33%) in LP, with no significant difference (P = 0.61).Among the 42 patients with advanced/recurrent disease, 61 surgeries were performed: 14 diagnostic procedures and 47 cytoreductive surgeries. Of the 47, there was no difference in operating room time (P = 0.10). There was no difference in EBL or LOS between CL and RALS (P = 0.82, P = 0.87); however, both were less in CL (P < 0.001 and P = 0.02) and RALS (P = 0.01 and P = 0.02) compared with LP. There were 5 (63%) intraoperative transfusions in LP and none in CL or RALS. When including all surgeries for advanced/recurrent disease, there was 1 intraoperative complication (12%) in LP. There was no difference in postoperative complications between groups (P = 0.89); 8 patients (19%) had postoperative complications in CL, 2 (18%) in RALS, and 2 (25%) in LP. Overall, there were no grade 4 or 5 complications and no perioperative or intraoperative deaths. CONCLUSIONS: In our experience, perioperative outcomes are comparable between CL and RALS in both early and advanced/recurrent disease and not inferior to laparotomy, making CL and RALS an acceptable approach in selected patients.

Strategies to minimize adhesion formation after surgery.

OBJECTIVES: To compare the potential for postoperative laparoscopic adhesion formation utilizing either monopolar cautery or ultrasonic energy and to determine whether there is added benefit with the addition of a suspension of hyaluronate/carboxymethylcellulose in saline versus saline alone. METHODS: Injuries were induced in rabbits by using monopolar cautery on 1 uterine horn and adjacent sidewall and ultrasonic energy on the opposite. Hyaluronate/carboxymethylcellulose or saline was added to every other animal. Autopsies were performed after 3 weeks. Clinical and pathologic scoring of adhesions was performed by blinded investigators. RESULTS: A very significant difference occurred in pathologic adhesion scores favoring the ultrasonic scalpel when the animals were treated with saline. However, a borderline significant difference was found in pathologic scores favoring the ultrasonic scalpel compared to the monopolar cautery. There was no significant difference in clinical adhesion scores between the 2 modalities. No significant difference in either score was found with the addition of hyaluronate/carboxymethylcellulose or saline with either instrument. CONCLUSION: No benefit was found for adhesion prevention with hyaluronate/carboxymethylcellulose. Although no reduction was achieved in clinical adhesions, the ultrasonic scalpel resulted in fewer histologic signs of tissue inflammation in the early postoperative period, suggesting that further clinical adhesions might develop over time with cautery.

Ureteral injury due to a Harmonic scalpel during laparoscopic salpingo-oophorectomy.

We present an unusual complication of a ureteral injury occurring during a bilateral laparoscopic salpingo-oophorectomy with the Harmonic scalpel (HS). The case illustrates in the same patient the versatility of the HS as a laparoscopic surgical instrument and energy source while at the same time demonstrating the potential for adverse, unexpected complications.

Postoperative adhesion formation in a rabbit model: monopolar electrosurgery versus ultrasonic scalpel.

BACKGROUND AND OBJECTIVES: To determine if surgery using ultrasonic energy for dissection results in less adhesion formation than monopolar electrosurgical energy in the late (8 weeks) postoperative period. METHODS: Injuries were induced in rabbits by using ultrasonic energy on one uterine horn and the adjacent pelvic sidewall and using monopolar energy on the opposite side. Eight weeks postoperatively, the rabbits underwent autopsy and clinical and pathologic scoring of adhesions was performed by blinded investigators. RESULTS: There was no significant difference in clinical adhesion scores between the two modalities. The mean clinical score for monopolar cautery was 1.00 versus 0.88 for the Harmonic device (Ethicon Endo-Surgery, Cincinnati, Ohio) (P = .71). Furthermore, there was no significant difference found in the pathologic adhesion scores between the ultrasonic scalpel and monopolar energy. The mean pathologic score for monopolar electrosurgery was 4.35 versus 3.65 for the Harmonic scalpel (P = .30). CONCLUSION: Neither monopolar electrosurgery nor ultrasonic dissection is superior in the prevention of adhesion formation in the late postoperative period.

Major reconstructive surgery for pelvic organ prolapse in elderly women, including the medically compromised.

OBJECTIVE: To demonstrate the safety of performing extensive pelvic surgery for benign disease in elderly patients, many with significant chronic medical conditions. STUDY DESIGN: Thirty-four consecutive women over the age of 65 and many with significant chronic medical illnesses underwent extensive pelvic reconstructive surgery in a major teaching hospital. The same attending surgeon, in conjunction with several different chief residents in obstetrics and gynecology, performed all the procedures between November 1998 and December 2001. A variety of procedures for the correction of significant, symptomatic pelvic organ prolapse were utilized. Intra-operative, postoperative, immediate and, when possible, extended outcomes were analyzed. RESULTS: There were no instances of intraoperative or postoperative mortality or of major intraoperative morbidity. Major postoperative morbidity was uncommon and totally correctable. The vast majority of patients achieved immediate and long-term satisfactory relief of their symptoms. CONCLUSION: Extensive pelvic reconstructive surgery is safe and effective in the elderly, regardless of concomitant medical conditions. It is important that patients, primary care physicians and, in some cases, gynecologists be made aware of this fact so that this ever-expanding segment of the population not be denied treatment for the very distressing and often debilitating symptoms of pelvic organ prolapse.

A novel approach to teaching placement of a B-lynch suture: description of technique and validation of teaching model.

INTRODUCTION: Postpartum hemorrhage is a major cause of maternal morbidity and mortality throughout the world and uterine atony is the leading cause of postpartum hemorrhage. The B-Lynch brace suture is a fertility-sparing approach to treating intractable uterine atony at the time of cesarean delivery. However, many obstetricians lack confidence to perform this procedure, which they may not have performed during residency. In order to train all residents to perform the B-Lynch brace suture, we developed a realistic model by using a flank steak to imitate a gravid uterus. METHODS: A convenience sample of obstetrics-gynecology faculty and residents at different levels of training at a single large hospital participated in this pilot project. Each physician reported self-perceived understanding of and confidence in performing the B-Lynch procedure before and immediately after practicing the technique using the flank-steak model, via a Likert-type survey (scale 1  =  low, 5  =  high). A Wilcoxon matched-pairs signed rank test was used to compare the before and after responses. RESULTS: Thirty-four participants completed the flank-steak model training and pretraining/posttraining surveys. The median score (range) for self-perceived understanding was 4 (2-5) and increased to 5 (4-5) (P < .01) after exposure to the training model. The confidence scores rose from 3 (1-5) to 5 (4-5) (P < .01) after training. CONCLUSION: The flank-steak model for teaching the B-Lynch suture significantly improved resident and faculty self-perceived understanding of and confidence in performing this procedure, which is otherwise rarely practiced in residency.

Robotic-assisted laparoscopic transection and repair of an obturator nerve during pelvic lymphadenectomy for endometrial cancer.

BACKGROUND: Obturator nerve injury may occur in gynecologic surgery, particularly in cases in which extensive pelvic sidewall retroperitoneal dissection is performed. The lack of tactile feedback from the robotic surgical system may contribute to obturator nerve injury. If surgical division occurs, microsurgical end-to-end anastomosis of the obturator nerve may be performed. CASE: A 76-year-old woman with stage IA endometrial adenocarcinoma sustained a left obturator nerve transection during pelvic lymphadenectomy that was recognized immediately. Robotic-assisted laparoscopic repair was performed successfully, with the patient experiencing no residual neuropathy 6 months postoperatively. CONCLUSION: Robotic-assisted laparoscopic repair is feasible for the treatment of obturator nerve injury.