Distribution of lymph node metastases in esophageal carcinoma [TIGER study]: study protocol of a multinational observational study.

BACKGROUND: An important parameter for survival in patients with esophageal carcinoma is lymph node status. The distribution of lymph node metastases depends on tumor characteristics such as tumor location, histology, invasion depth, and on neoadjuvant treatment. The exact distribution is unknown. Neoadjuvant treatment and surgical strategy depends on the distribution pattern of nodal metastases but consensus on the extent of lymphadenectomy has not been reached. The aim of this study is to determine the distribution of lymph node metastases in patients with resectable esophageal or gastro-esophageal junction carcinoma in whom a transthoracic esophagectomy with a 2- or 3-field lymphadenectomy is performed. This can be the foundation for a uniform worldwide staging system and establishment of the optimal surgical strategy for esophageal cancer patients. METHODS: The TIGER study is an international observational cohort study with 50 participating centers. Patients with a resectable esophageal or gastro-esophageal junction carcinoma in whom a transthoracic esophagectomy with a 2- or 3-field lymphadenectomy is performed in participating centers will be included. All lymph node stations will be excised and separately individually analyzed by pathological examination. The aim is to include 5000 patients. The primary endpoint is the distribution of lymph node metastases in esophageal and esophago-gastric junction carcinoma specimens following transthoracic esophagectomy with at least 2-field lymphadenectomy in relation to tumor histology, tumor location, invasion depth, number of lymph nodes and lymph node metastases, pre-operative diagnostics, neo-adjuvant therapy and (disease free) survival. DISCUSSION: The TIGER study will provide a roadmap of the location of lymph node metastases in relation to tumor histology, tumor location, invasion depth, number of lymph nodes and lymph node metastases, pre-operative diagnostics, neo-adjuvant therapy and survival. Patient-tailored treatment can be developed based on these results, such as the optimal radiation field and extent of lymphadenectomy based on the primary tumor characteristics. TRIAL REGISTRATION: NCT03222895 , date of registration: July 19th, 2017.

Novel Anastomotic Technique for Uterine Transplant Using Utero-ovarian Veins for Venous Drainage and Internal Iliac Arteries for Perfusion in Two Laparoscopically Harvested Uteri.

STUDY OBJECTIVE: To evaluate 2 cases of uterine transplant surgery that used utero-ovarian veins as outflow channels, internal iliac arteries for perfusion, and the organ harvest surgery performed laparoscopically. DESIGN: Case study (Canadian Task Force Classification III). SETTING: An urban, private, tertiary care hospital. PATIENTS: Two patients, ages 30 and 24years, diagnosed with absolute uterine factor infertility secondary to Mayer-Rokitansky-Küster-Hauser syndrome underwent related living donor uterine transplants; donors were their mothers with normal menses. INTERVENTIONS: Retrieval of organs through minilaparotomy and laparoscopic harvest of donor internal iliac arteries and ovarian veins. MEASUREMENTS AND MAIN RESULTS: Anastomosis was completed with bilateral donor internal iliac arteries to recipient internal iliac arteries in an end-to-end manner and with bilateral donor ovarian veins to recipient external iliac veins in an end-to-side manner. The lengths of utero-ovarian veins of both donors were 11 and 11cm on both sides; the lengths of the internal iliac arteries of both donors were 10 and 7.5cm on the left side and 10 and 6cm on the right side. The operative times for harvest surgery, bench surgery and transplant surgery were 2:40 and 3:20 hours, 34:32 and 33:30 min and 4:00 and 4:30 hours respectively for recipients 1 and 2. Daily postoperative uterine Doppler was completed through day 8 and then every other day and showed good intrauterine blood flow (i.e., low resistance arcuate vessel flow; resistance index < .5). Cervical biopsies on postoperative days 7 and 14 showed no evidence of rejection in either recipient. Both recipients started menstruating within 2 months of surgery. CONCLUSION: By using ovarian veins as outflow channels, the challenges involved in dissection along the internal iliac vein are avoided, and harvesting the donor internal iliac artery reduces the tension on vascular anastomosis. The selection of vessels to be harvested could make the technique reproducible, although larger studies are warranted to confirm results.

Evaluation of 5-year results of laparoscopic transhiatal oesophagectomy as a single-centre experience.

INTRODUCTION: Minimal Invasive Surgery of oesophageal cancers is gaining popularity. We have published our Thoracoscopic Esophagectomy results. The present study focuses on our expertise of TransHiatal Esophagectomy. MATERIALS AND METHODS: 287 patients underwent Esophagectomies for Cancer of Esophagus at Galaxy Care Laparoscopy Institute from January 2010 to December 2014 after thorough assesment. Out of these, 81 patients underwent laparoscopic trans hiatal esophagectomies. Their charts were reviewed retrospectively for intraoperative and postoperative results. The median follow up was 28 months. RESULTS: Out of 81 patients,76 patients had R0 resection and 5 had R1. The average lymphnode yield was 20,average survival was 28months. 3 patients had local recurrence,18 had regional recurrence and 30 had distant recurrence. Average operating time was 140 min,mean blood loss was 80 ml. Average Post-operative ICU stay was 1 day and hospital stay 7 days. CONCLUSION: Classic THE has limitations which can be overcome by the use of laparoscopic techniques. Laparoscopic approach for THE has better magnified vision facilitating better clearance under vision. Hence we recommend laparoscopic technique for THE to minimize morbidity and improve oncologic results.

Laparoscopic-Assisted Uterus Retrieval From Live Organ Donors for Uterine Transplant.

STUDY OBJECTIVE: The authors present the first ever laparoscopic-assisted uterus retrieval in a live donor for uterus transplant. DESIGN: A step-by-step surgical demonstration. SETTING: Galaxy CARE Laparoscopy Institute, Pune, India. PATIENTS: Two patients, ages 21 and 26 years, with Mayer-Rokitansky-Küster-Hauser syndrome and Asherman syndrome, respectively, with their mothers as donors. INTERVENTIONS: A 12-member team was formed. After a review of the available literature on uterine transplant, a protocol was formulated and submitted to the Institutional Review Board (IRB). Approval from the Institutional Review Board was obtained. Thorough screening of the candidates was done. Two consecutive uterine transplants were done on 2 successive days. Vessels were harvested laparoscopically in both donors. Uterus was retrieved through a small abdominal incision, to prevent any injury to the uterus and harvested vessels. Uterus was transplanted in the recipients by end-to-side anastomosis of the harvested vessels to the external iliac vessels, followed by anchoring of supports of the donor uterus to those of the recipients. MEASUREMENTS AND MAIN RESULTS: Surgical intra- and postoperative parameters, postoperative investigations, and follow-up data of 4 months. The operative time for laparoscopic donor surgery was 4 hours. Bench surgery took 45 minutes. The recipient surgery was completed in 4 hours. There were no intraoperative or immediate postoperative complications. Both recipients started menstruating after 34 days and 48 days, respectively, and have had 3 cycles of menses at regular intervals to date. After discharge, follow-up cervical biopsies at 3 weekly intervals showed no signs of rejection. Uterine artery Doppler ultrasound showed good flow in both patients. CONCLUSION: Laparoscopic-assisted donor retrieval is feasible and affords all advantages of a minimally invasive technique. It helps in better dissection of vessels, shortens the operative time, and helps minimize tissue handling, thereby reducing the morbidity of the procedure.

Laparoscopic-Assisted Uterus Retrieval From Live Organ Donors for Uterine Transplant: Our Experience of Two Patients.

STUDY OBJECTIVE: To report the first ever laparoscopic-assisted live donor uterus retrieval in 2 patients for uterus transplant. DESIGN: Case study (Canadian Task Force classification III). SETTING: Galaxy CARE Laparoscopy Institute, Pune, India. PATIENTS: Two patients with absolute uterine factor infertility with their mothers as donors. INTERVENTIONS: In vitro fertilization and uterine transplant. MEASUREMENTS AND MAIN RESULTS: A 12-member team was formed, and approval for transplant was obtained from the institutional review board. Pretransplant, in vitro fertilization for both patients was done. Two consecutive uterine transplants were done on 2 successive days. Vessels were harvested laparoscopically in both donors. Uterus and harvested vessels were retrieved by a small abdominal incision to prevent injury and infection. The uterus was transplanted in the recipients by end to side anastomosis of the harvested vessels to external iliac vessels, followed by anchoring of supports of the donor uterus to those of the recipients. Surgical intra- and postoperative parameters, postoperative investigations, and follow-up data of 6 months were measured. Operative time for laparoscopic donor surgery was 4 hours. Bench surgery took 45 minutes. Recipient surgery time was 4 hours. There were no intraoperative or immediate postoperative complications. Both the recipients started menstruating after 34 days and 48 days, respectively, and have had 6 cycles of menses at regular intervals. Uterine artery Doppler showed good flow in both patients. Hysteroscopy-guided cervical biopsies were used as a method of surveillance of graft rejection after uterine transplant. Office hysteroscopy was done after 2 months in both patients, and hysteroscopy-guided endometrial and cervical biopsies were taken. Minimal slough was seen on the endometrium in the patient with Mayer-Rokitansky-Küster-Hauser syndrome, which was removed. Repeat hysteroscopy after 10 days showed a healthy endometrium. CONCLUSIONS: Laparoscopic-assisted uterus donor retrieval is feasible and affords all the advantages of a minimally invasive technique, thereby reducing the morbidity of the procedure. It helps in better dissection of the vessels, shortens the operative time, and helps to minimize tissue handling of the harvested uterus and vessels.

Our Experience of Laparoscopic Anterior Exenteration in Locally Advanced Cervical Carcinoma.

STUDY OBJECTIVE: To show the feasibility, technique, and results of laparoscopic anterior exenteration in selected patients. DESIGN: A retrospective cohort study. SETTING: Galaxy Care Laparoscopy Institute, Pune, India. PATIENTS: Seventy-four of 85 patients who underwent laparoscopic anterior exenteration for stage IVA carcinoma of the cervix from January 2005 to January 2015 were analyzed; the median follow-up was 30 months. Contrast-enhanced computed tomographic imaging of the abdomen and pelvis was performed for all patients. INTERVENTIONS: The same surgeon and team performed all the operations for uniformity in 10 operative steps. MEASUREMENTS AND MAIN RESULTS: The mean operative time was 180 minutes, and the mean blood loss was 160 mL. The mean hospital stay was 6 days. The average number of lymph nodes removed was 21.4. Surgical margins were negative in all patients. Forty-two patients had positive lymph nodes. Chemoradiation was given to those with positive lymph nodes. Perioperative complications occurred in 15 (20.27%) patients including deep vein thrombosis, urinary tract infection, ureterosigmoid leak (n = 2/74), and so on. Positron emission tomographic imaging and computed tomographic scanning were performed at 6 months after surgery and 6 months after adjuvant therapy in those with positive lymph nodes. There was no immediate postoperative mortality. The overall survival rate at 5 years was 25%. CONCLUSION: Laparoscopic anterior exenteration is feasible in cases of advanced carcinoma of the cervix. Results have shown that in selected patients this procedure is associated with good long-term survival.

Fascial Anatomy and Its Relevance in Safe Laparoscopic Hysterectomy.

STUDY OBJECTIVE: To demonstrate the importance of being familiar with the anatomy of the endopelvic fascia as seen by laparoscopy to perform safe laparoscopic hysterectomies. DESIGN: Combination of surgical videos and design diagrams. SETTING: Compiled high-definition surgical videos from the Galaxy Care Laparoscopy Institute, Pune, India. These videos clearly demonstrate the anatomy of the endopelvic fascia and describe tips to avoid damage to the major structures, including the major vessels, ureter, bowel, bladder, and endopelvic fascia. The laparoscopic view of the anatomy with the current camera system is an excellent tool to demonstrate and teach pelvic anatomy, which can be applied to surgical principles in difficult benign and oncological cases. INTERVENTION: We used a total laparoscopic approach to demonstrate the fasciae that were seen during various types of hysterectomies. The video shows the following: (1) the posterior leaf of the broad ligament was opened until it reached the apex of the uterosacral ligament; (2) the anterior leaf of broad ligament was opened until it reached the vesico-uterine peritoneal reflection; (3) the principles of bladder dissection; (4) the pubocervico-vesical fascia and its relevance to bladder dissection; (5) the relevance of the anatomy of the uterine artery, vein, and ureter with endopelvic fascia within the leaves of the broad ligament; (6) Denonvillier's fascia dissection technique for dissection of the rectum away from the vagina; (7) the anatomy of the vesicocervical ligaments, forming the ureteric tunnel; (8) the dissection principles of lateralizing the ureter in the retrovesical region; (9) the endopelvic fascia reflection, which continued caudally, covering the pelvic floor; and (10) the relevance of the anatomy of the endopelvic fascia and the stress urinary incontinence treatment technique. CONCLUSION: Understanding the anatomy of the fasciae of the pelvis helps to create avascular planes and is crucial for performing safe hysterectomies.

Duplication of Conventional Multiport Laparoscopic Radical Hysterectomy Steps with Other Minimal Access Modalities (LESS, OASIS, Robotic).

STUDY OBJECTIVE: To duplicate the steps of conventional multiport laparoscopic radical hysterectomy by 3 other minimal access modalities: robotic radical hysterectomy, laparoendoscopic single-site surgery (LESS), and orifice-assisted small-incision surgery (OASIS). DESIGN: Institutional Review Board approval was obtained. Between January 2009 and December 2012, the charts of the patients who had undergone radical hysterectomy by these 4 minimal access modalities were analyzed. SETTING: Galaxy Care Laparoscopy Institute, Pune, India. PATIENTS: Fifteen patients in each arm with stage IB1 cervical cancer with a histopathological report of squamous cell carcinoma were analyzed. All patients had undergone radical hysterectomy by a conventional multiport, robotic, LESS, or OASIS technique. The type of procedure was decided by joint consultancies of doctor and patient. All patients were analyzed retrospectively for time, blood loss, oncologic clearance, and complications. The median follow-up of all patients was 12 months (range, 8-18 months). INTERVENTION: The "Pune technique" of radical hysterectomy consists of 6 steps: (1) posterior U cut; (2) dissection of pouch of Douglas; (3) pararectal space dissection; (4) anterior U cut; (5) uretric tunnel dissection; and (6) ilio-obturator lymph node dissection. CONCLUSION: The radical hysterectomy is a type B radical hysterectomy. Proper patient selection plays an important role in radical hysterectomy with different minimal access operative modalities. Parametrium clearance of 2.25 to 3.5 cm can be obtained with different modalities [1-5]. As of the writing of this report, none of the 60 patients evaluated had experienced recurrence, and all are disease-free. The study period was 4 years. To conclude, our data indicate that the steps of conventional multiport radical hysterectomy by the Pune technique can be duplicated by other minimal access modalities, including robotic radical hysterectomy, LESS, and OASIS.

Laparoscopic anterior exenteration with intracorporeal uretero-sigmoidostomy.

STUDY OBJECTIVE: To demonstrate the feasibility of laparoscopic anterior exenteration with intracorporeal ureterosigmoidostomy. DESIGN: After Institutional Review Board approval was obtained, patients who had undergone laparoscopic anterior exenteration with intracorporeal ureterosigmoidostomy were analyzed. PATIENTS AND METHODS: Fifty-seven patients with advanced cervical carcinoma, stage IV A, since 2005 were analyzed retrospectively. The preoperative workup was done with contrast-enhanced computed tomography abdomen-pelvis and positron emission tomography (PET) scans. Patients were analyzed for operative time, blood loss, and complications. Patient follow-up was done monthly for the first 3 months, every 3 months for 1 year, and then every 6 months for 3 years. Postoperative follow-up was done with PET scans. SETTING: Galaxy Care Laparoscopic Institute, Pune, India. INTERVENTIONS: Operative steps were as follows: MEASUREMENTS AND RESULTS: The mean operative time was 180 minutes (range, 140-240 minutes), and mean blood loss was 100 mL (range, 50-200 mL), as measured by the amount of blood in the suction machine. The median duration of hospital stay was 4 days (range, 3-7 days). The mean number of lymph nodes retrieved was 12 (range, 9-21). Surgical margins were negative in all patients with a lateral margin >2 cm. Twenty-eight patients had positive lymph nodes. Chemoradiotherapy was given to the patients with positive lymph nodes. Minor leak was present in 11 patients in the immediate postoperative period, for which no active intervention was required. Hyperchloremic metabolic acidosis which was seen on biochemical parameter but clinically patient have no manifestation and was treated with sodium bicarbonate. A postoperative PET scan was done at 6 months after the completion of adjuvant therapy in lymph node-positive patients and 6 months after surgery in node-negative patients. CONCLUSION: Exenteration has a definitive role in the treatment of advanced cervical cancer. Results have demonstrated the feasibility of this procedure [1-4].

Robotic transthoracic esophagectomy.

BACKGROUND: We have initially published our experience with the robotic transthoracic esophagectomy in 32 patients from a single institute. The present paper is the extension of our experience with robotic system and to best of our knowledge this represents the largest series of robotic transthoracic esophagectomy worldwide. The objective of this study was to investigate the feasibility of the robotic transthoracic esophagectomy for esophageal cancer in a series of patients from a single institute. METHODS: A retrospective review of medical records was conducted for 83 esophageal cancer patients who underwent robotic esophagectomy at our institute from December 2009 to December 2012. All patients underwent a thorough clinical examination and pre-operative investigations. All patients underwent robotic esophageal mobilization. En-bloc dissection with lymphadenectomy was performed in all cases with preservation of Azygous vein. Relevant data were gathered from medical records. RESULTS: The study population comprised of 50 men and 33 women with mean age of 59.18 years. The mean operative time was 204.94 mins (range 180 to 300). The mean blood loss was 86.75 ml (range 50 to 200). The mean number of lymph node yield was 18. 36 (range 13 to 24). None of the patient required conversion. The mean ICU stay and hospital stay was 1 day (range 1 to 3) and 10.37 days (range 10 to 13), respectively. A total of 16 (19.28%) complication were reported in these patents. Commonly reported complication included dysphagia, pleural effusion and anastomotic leak. No treatment related mortality was observed. After a median follow-up period of 10 months, 66 patients (79.52%) survived with disease free stage. CONCLUSIONS: We found robot-assisted thoracoscopic esophagectomy feasible in cases of esophageal cancer. The procedure allowed precise en-bloc dissection with lymphadenectomy in mediastinum with reduced operative time, blood loss and complications.

Nerve-sparing radical hysterectomy made easy by laparoscopy.

STUDY OBJECTIVE: To evaluate the technical feasibility of nerve-sparing radical hysterectomy performed laparoscopically. PATIENTS: Thirty-five women with cervical cancer stage Ia1 or Ib1. INTERVENTIONS: All patients underwent laparoscopic nerve-sparing hysterectomy. MEASUREMENTS AND MAIN RESULTS: Oncologic results were comparable to those of conventional laparoscopic radical hysterectomy. There was complete recovery of bladder function after removal of the Foley catheter. Results of urodynamic studies at 3 weeks after surgery were normal. CONCLUSION: Oncologic and functional results are comparable to those of conventional laparoscopic radical hysterectomy. Magnification enabled by laparoscopy is helpful in better dissection and preservation of nerve anatomy.

Single-site laparoscopic radical hysterectomy using conventional ports and instruments.

STUDY OBJECTIVE: To study the technical feasibility of performing a radical hysterectomy via laparoscopic single-site surgery LESS. PATIENT: A 45-year-old woman with cervical cancer stage IA2. INTERVENTION: Biopsy report showed invasive keratinizing squamous cell carcinoma, grade II. We duplicated the steps of our "Pune technique" of laparoscopic radical hysterectomy to perform a radical hysterectomy via laparoscopic single-site surgery using conventional ports and instruments. MEASUREMENTS AND MAIN RESULTS: Oncologic clearance was comparable to that of conventional laparoscopic radical hysterectomy. Operative time was 120 minutes, and blood loss was 50 mL. CONCLUSION: Reduced port laparoscopic radical hysterectomy is technically feasible. Oncologic clearance and functional results are comparable to those of the multiport variant, with good cosmetic results.

Understanding the pelvic anatomy.

The pelvic anatomy is constant, with few variations. It has a distinct appearance when observed using the 2-dimensional laparoscope. Thus it is important to master the laparoscopic anatomy and use this knowledge to perform better surgery. The laparoscope offers better vision in a narrow space and thus helps better understanding of the anatomy than what can be seen during open surgery. The objectives of this video are to enable the observer to become familiar with the surgical anatomy, to apply anatomical knowledge to develop fine surgical skills, and to address the myths of open surgical anatomy. The lucid graphics, images, and commentary will enable easy understanding of the pelvic anatomy.

Laparoscopic Supracolic Pancreaticoduodenectomy: A Novel Technique For Complete Uncinate Process Resection.

BACKGROUND: Laparoscopic pancreaticoduodenectomy represents one of the most advanced surgical approaches for periampullary and pancreatic head tumors. This article aims to describe the novel technique for complete resection of the uncinate process from supracolic compartment only and summarizes the results from our institute. METHODOLOGY: Retrospective review of prospectively maintained database was performed for patients who underwent laparoscopic pancreaticoduodenectomy from April 2008 to March 2012 at our institute. RESULTS: A total of 38 patients with a mean age of 56.5 years (range: 35-70) underwent laparoscopic pancreaticoduodenectomy with this novel approach. Complete resection of uncinate process was achieved in 33 (86.84%) patients. The mean total operative time and resection time was 231.70 mins (range: 210-450) and 116.50 mins (range: 80-250), respectively. The mean blood loss was 183 ml (range 60-340). Major perioperative morbidity included pancreatic anastomotic leak (n = 3), billiary leak (n = 1) and hemorrhage (n = 1). Mean hospital stay was 14 days (range: 12-25 days). CONCLUSION: This novel supracolic approach for laparoscopic pancreaticoduodenectomy is feasible, safe and less time consuming. This technique can help achieving oncological outcomes comparable to those of the other techniques; though with the minimum invasion. This procedure can be performed conveniently by surgeons with substantial knowledge, experience and skills.

Indian experience of robotics in gynecology.

AIMS: To study the role of robotics in various gynaecological cases, benign and malignant. MATERIALS AND METHODS: A total number of 80 cases have been analyzed. Operative time, estimated blood loss, hospital stay, complications, conversion rates have been retrospectively studied in all cases. Nodal yield, vaginal margin and paracervical clearance have been studied in all malignant cases. This investigation was conducted at a single minimal access surgery institute. RESULTS: Of total 80 cases, 29 were benign and 51 were malignant cases. In benign cases, total robotic hysterectomies were 24, 2 cases of tubotuboplasty, 1 case of endometriotic cyst excision, 1 case of metroplasty and 1 case of rectovaginal fistula. In 51 cases, 37 of radical hysterectomy, 9 exenterations and 6 were parametrectomy. In benign cases, mean operative time was 80 min, estimated blood loss was 20 ml, mean hospital stay was for 1 day, no major complications and no conversions. In malignant cases, mean operative time was 122 min, estimated blood loss was 50-100ml, 2 cases of ureteric fistulas and no conversions, nodal yield was 30, vaginal margin was 2.5-3.8 cm and para cervical clearance was 3-3.5 cm. CONCLUSIONS: Ours is the largest series of robotic surgery in gynecological procedures in India. Benign and malignant cases were addressed robotically showing the feasibility.

More with LESS: a novel report of nerve sparing radical hysterectomy performed using LESS.

Laparoendoscopic single-site surgery (LESS) and natural orifice translumenal endoscopic surgery are now being used in gynecologic oncologic procedures. We used our expertise with LESS to perform nerve-sparing laparoscopic radical hysterectomy. A 45-year-old woman with stage IA2 cervical cancer was referred to us. The biopsy specimen showed grade II invasive keratinizing squamous cell carcinoma. We duplicated the steps of our laparoscopic nerve-sparing radical hysterectomy procedure to perform a nerve-sparing radical hysterectomy via LESS using conventional ports and instruments. Oncologic clearance was comparable to that in conventional laparoscopic radical hysterectomy. Bladder function recovered completely after removal of the Foley catheter. Nerve-sparing laparoscopic radical hysterectomy using fewer ports is technically feasible. The oncologic clearance and functional results are comparable to those in the multiport variant.

Laparoscopic transvesical approach for vesicovaginal fistula repair.

STUDY OBJECTIVE: To access the technical feasibility of performing laparoscopic repair of vesicovaginal fistula. MATERIAL AND METHODS: We attempted a laparoscopic repair of vesicovaginal fistula in five women with a history of urinary leakage via the vagina after vaginal hysterectomy. Five pelvic ports were used. The surgical procedure was performed using the same principles as for open surgery, i.e., separation of the vaginal wall from the bladder wall, repair of the fistula, and interposition of the omentum. RESULTS: There was early recovery of the patients in terms of continence, with less chance of recurrence. Results were comparable to those with the vaginal approach. CONCLUSION: The use of minimally invasive surgery for vesicovaginal fistula repair helps to ease the suturing deep in the pelvis, and the magnification facilitates good identification of tissues planes and thus better mobilization of the vaginal and bladder walls and decreases postoperative morbidity.

The past, present and future of minimally invasive endoscopy in gynecology: a review and speculative outlook.

Over the last twenty-five years, minimally invasive surgery (MIS) has evolved in a relatively short period of time to overtake the centuries-old visionary and pioneering groundwork of our outstanding colleagues in all surgical disciplines. This overview on the development of gynecological endoscopy, at the invitation of SMIT, highlights past achievements and describes present challenges. It emphasizes future opportunities and possibilities to foster interdisciplinary collaboration and integrate emerging endoscopic, imaging and stereotactic surgical technologies to improve patient safety, enhance quality of care and advance surgical education. This article will introduce younger colleagues to the exciting world of contemporary gynecologic endoscopy and help them appreciate the immense technology-laden opportunities that the future holds for those who are prepared to follow in the footsteps and aspirations of our founding surgical colleagues.

Anatomical Description of Anterior Parametrium: A Probable Answer to Pelvic Recurrence Following Radical Hysterectomy.

A prospective analysis of a retrospective data of patients with cervix carcinoma treated by minimal invasive surgery at high-volume gynecology oncology center analyzing that minimal access surgery is an acceptable treatment modality in cervix carcinoma. The study included 423 patients who underwent laparoscopic/robotic radical hysterectomy after pre-operative evaluation after taking their consent and obtaining ethical approval from the IRB. Post-operatively, patients were followed up at regular intervals for clinical examination and ultrasonography for a median range of 36 months. A PET scan was done only if there was any suspicious finding on clinical examination or ultrasonography. Patients with parametrial involvement, positive vaginal margins, and nodal involvement were treated with chemotherapy/radiotherapy. Four hundred twenty-three patients of cervix carcinoma were treated with minimal access surgery. Average duration of surgeries was 92 min. Median range of duration of post-operative follow-up was 36 months. None of the patients had positive resection margins indicating adequate parametrectomy with complete oncological clearance. On post-operative follow-up, only 2 patients had vaginal recurrence which is comparable to that observed in open surgery and no pelvic recurrence. With the understanding of the anatomical landmarks of the anterior parametrium and development of skills for adequate oncological clearance, minimal access surgery should be the preferred surgical modality in carcinoma of the cervix.

Endometriosis Resection Using Nerve Sparing Versus Non-nerve Sparing Surgical Techniques.

Introduction: Endometriosis is the condition in which there are ectopic endometrial tissues outside the uterine cavity. The use of nerve sparing technique has been well established in the field of oncology, leading to better quality of life following radical oncologic procedures without compromising on the long-term survival. The objective of this study is to compare the quality of life in terms of sexual function and urinary function in women undergoing nerve sparing surgeries for endometriosis and those undergoing non-nerve sparing surgeries. Material and Methods: Data of 51 patients operated for endometriosis at Galaxy Care Laparoscopic Institute, Pune, India between 1st January 2020 till 31st December 2020 were collected and analysed. We included patients in age group between 38 and 44 years in monogamous relationship, with moderate to severe endometriosis (Revised American Society of Reproductive Medicine r-ASRM score of 16 and above 5), being operated for hysterectomy along with ureterolysis and/or bowel resection (including shaving of rectal endometriosis, discoid resection, segmental resection), and excision of large ovarian endometriomas (> 3 cm size) with cul-de-sac obliteration. Results: The patients were evaluated for the following factors: age, parity, nature of surgery done, immediate intraoperative complications (bowel injury, bladder injury, ureteric injury), operative time in minutes, average blood loss, length of hospital stay, days to removal of foley's catheter and postoperative urinary and sexual function which were assessed on follow up visit and a 1-year follow up interview. We found that the urinary and sexual function in the group undergoing nerve sparing surgeries was significantly better than the patients undergoing non-nerve sparing surgeries. Conclusion: Laparoscopic nerve sparing approach for clearance of endometriosis has allowed better quality of life post surgery. Proper understanding and demonstration of pelvic neuroanatomy has made this approach feasible and achievable in carefully selected patients.