The virtues and pitfalls of minimally invasive surgery for gynecological malignancies: an update.

Operative laparoscopy is still jockeying for its place in the surgical management of gynecological malignancies. Its usefulness in staging these malignancies continues to be investigated, as does its ability to convert abdominal procedures to vaginal procedures. Recent articles also address the role of operative laparoscopy in less common procedures, as well as the curiosity of investigators to gain a better understanding of the 'consequences' of operative laparoscopy by using animal models. The reader is updated by a review of the reports published over the past year and a half.

Preliminary technique of laparoscopic extraperitoneal infrarenal paraaortic lymphadenectomy in the porcine model.

We developed an extraperitoneal approach to laparoscopic infrarenal paraaortic lymphadenectomy in the porcine model, with the ultimate aim of shortening the long learning curve of this procedure in humans. Surgery was performed on four females pigs with three 10-mm cannulas placed along the midaxillary line in prone position. The first and second pigs underwent subsequent laparotomy to evaluate the adequacy of lymph node dissection and complications. In all four animals, complete infrarenal paraaortic lymphadenectomy was successful, retrieving between 6 and 11 lymph nodes (average 9). Laparotomy in the first two animals confirmed adequate lymphadenectomy. No complications occurred. Operating time was shortened dramatically with each procedure (180, 120, 50, 40 min). In the porcine model this approach provides excellent exposure to the entire paraaortic lymphatic chain, is safe, and has a remarkably short learning curve. Development of a similar technique in humans may have significant advantages, including short learning curve, feasibility in obese patients and those with peritoneal adhesions, decreased adhesion formation, and reduced bowel complications associated with postoperative adjuvant irradiation. Further studies are indicated.

Transabdominal cerclage: a laparoscopic approach.

BACKGROUND: The placement of a transabdominal cervical cerclage has been regarded as considerably more morbid than a transvaginal cerclage, in part due to the need for two laparotomies. We describe a technique for the laparoscopic placement and removal of a transabdominal cerclage. CASES: Two cases of women with insufficient cervical tissue to place a transvaginal cerclage were managed with a transabdominal cerclage. In one case, the cerclage was placed laparoscopically; in the other, the band was removed, facilitating uterine evacuation following the diagnosis of a missed abortion. In both cases a laparotomy was avoided. CONCLUSION: Laparoscopic placement and removal of a transabdominal cerclage are promising options in the treatment of an incompetent cervix.

Concentrations of carotenoids, tocopherols, and retinol in paired plasma and cervical tissue of patients with cervical cancer, precancer, and noncancerous diseases.

Paired blood (collected after an overnight fast) and cervical tissue (cancerous, precancerous, and noncancerous) samples were obtained from 87 patients (age, 21-86 years) who had a hysterectomy or biopsy due to cervical cancer, precancer (cervical intraepithelial neoplasia I, II, and III), or noncancerous diseases. The samples were analyzed using high-performance liquid chromatography for 10 micronutrients (lutein, zeaxanthin, beta-cryptoxanthin, lycopene, alpha-carotene, beta-carotene, cis-beta-carotene, alpha-tocopherol, gamma-tocopherol, and retinol). The results indicated that: (a) among the three patient groups, the mean plasma concentrations of all micronutrients except gamma-tocopherol were lowest in the cancer patients; however, the mean tissue concentrations of the two tocopherols and certain carotenoids were highest in the cancerous tissue; and (b) among the 10 micronutrients, only the concentrations of beta-carotene and cis-beta-carotene were lower in both the plasma and tissue of cancer and precancer patients than in those of noncancer controls. These results suggest that: (a) not all of the micronutrient concentrations in plasma reflect the micronutrient concentrations in cervical tissue; thus, in some cases, it may be necessary to measure the tissue micronutrient concentrations to define the role of the micronutrients in cervical carcinogenesis; and (b) maintaining an adequate plasma and tissue concentration of beta-carotene may be necessary for the prevention of cervical cancer and precancer.

Laparoscopic staging of endometrial cancer: the learning experience.

OBJECTIVE: To evaluate our learning-curve experience with laparoscopic management of endometrial carcinoma. METHODS: Retrospective review of our first 125 patients with endometrial cancer who were managed laparoscopically. The patient population was reviewed in a chronological manner, noting patient demographics, operative procedure and times, estimated blood loss, hospital stay, complications, and pathology. RESULTS: Overall, the mean age was 68.6 years (range 29-89), the mean weight was 160 pounds (range 97-328), and the mean Quetelet index was 27.8 (range 17.8-56.4). Metastatic disease was discovered in 28.8% (17/59) of patients with grade 2 or 3 lesions. There was no statistically significant variation in any of these parameters throughout the study. Operative times for staging without lymphadenectomy decreased significantly from a mean of 163 minutes to 99 minutes (p < .001). Operative times for staging with lymphadenectomy decreased from a mean of 196 minutes to 128 minutes (p < 0.02). Hospital stay decreased from a mean of 3.2 days in the first quarter of our study to 1.8 days (p < .0001). The overall average complication rate of 4% (two enterotomies, two cystotomies, and a transected ureter) did not vary. However, the rate of conversion to laparotomy dropped significantly from 8% (2/25) to 0% (0/100). CONCLUSIONS: We found that operative times and hospital stays for laparoscopic staging of endometrial cancer continued to drop after 125 cases. While the ability to detect metastatic disease and the rate of major complications appear unrelated to length of the operator experience, the conversion rate to laparotomy decreases with operator experience. Learning-curve parameters must be recognized by physicians, patients, and researchers for a host of reasons.

Laparoscopic bowel injuries among gynecologic patients.

Bowel injury is an uncommon but recognized risk of operative laparoscopy. Because of the significant morbidity that can occur with this complication, it is important that clinicians be aware of its incidence, presentation, and management. This manuscript outlines the common causes of bowel injury, including herniation and traumatic bowel perforation. Management of laparoscopic bowel injuries is discussed and recommendations are made for avoidance of such complications.

Laparoscopic management of suspicious adnexal masses.

OBJECTIVE: Our aim was to evaluate the feasibility and applicability of operative laparoscopy in the management of adnexal masses that do not meet the standard serum CA 125 and ultrasonographic criteria for benignity. STUDY DESIGN: One hundred thirty-eight patients underwent operative laparoscopy for removal of suspicious adnexal masses. The CA 125 level was > 35 mlU/ml in 39 of 138 (28%) patients; ultrasonographic findings were abnormal in 127 of 138 (92%); masses were > 10 cm in 43 of 138 (32%) of patients. RESULTS: Malignancies were discovered in 14% (19/138) of patients. Eight percent (11/138) of the procedures were converted to laparotomy, six because of inability to dissect the mass laparoscopically and five for staging or debulking of carcinoma. Operative times ranged from 25 to 210 minutes, with a mean of 86. Three major complications were encountered-an enterotomy and a lacerated vena cava, both of which were repaired laparoscopically, and a small bowel herniation through a lateral port site that required reoperation. Hospital stays ranged from 0 to 11 days, with a mean of 1.5. In two patients with "apparent" stage I adnexal carcinomas recurrence was diagnosed 6 and 38 months after surgery. CONCLUSIONS: Laparoscopic management of suspicious adnexal masses is technically feasible, with a low rate of morbidity and a short hospital stay. Adnexal carcinomas can be identified and managed appropriately with staging and complete resection as indicated.

Laparoscopic management of benign cystic teratomas during pregnancy.

OBJECTIVE: Our purpose was to evaluate the surgical management and outcome of laparoscopic removal of benign cystic teratomas during pregnancy. STUDY DESIGN: The records of women with benign cystic teratomas who were managed with operative laparoscopy during pregnancy were reviewed. RESULTS: Twelve women had laparoscopic removal of a benign cystic teratoma during pregnancy. Gestational ages at surgery ranged from 9 to 17 weeks, with a mean of 14 weeks. Cyst size ranged from 5 to 13 cm, with a mean of 8.5 cm. Intraoperative rupture of the cyst occurred in 10 of 12 (93%) women. No patient had evidence of chemical peritonitis. The mean operating time was 87 minutes and the mean postoperative hospital stay was 44 hours. No intraoperative or postoperative maternal or fetal complications occurred. CONCLUSIONS: Laparoscopic removal of a benign cystic teratoma of the ovary may be safely accomplished during pregnancy. In spite of a significant risk of cyst rupture, careful operative technique followed by copious irrigation of the pelvis may avoid chemical peritonitis and potential adverse sequelae.

Laparoscopic ovarian cystectomy for a benign teratoma in a 10-year-old girl.

A 10-year-old girl was diagnosed with an 8-cm mature cystic teratoma. An outpatient ovary-conserving cystectomy was performed, and the girl recovered fully in 24 hours. We suggest that laparoscopy can be effective in the conservative management of some gynecologic disorders in properly selected children.

A simple suturing technique for laparoscopic ligation of vascular pedicles.

We report on the performance of 348 adnexectomies and 35 uterine artery ligations for both benign and malignant disease using a simple laparoscopic suturing technique. Only 5-mm ports are required, and there was no morbidity directly associated with this approach. The procedure can be performed quickly, is relatively inexpensive, and allows hysterectomy and oophorectomy to be performed without bipolar electrocautery.

The role of laparoscopy in gynecologic oncology.

The use of laparoscopy in the management of gynecologic malignancies has significantly increased over the last 5 years. The safety and adequacy of pelvic and para-aortic lymphadenectomy has been established by several investigators. Patients with early carcinoma of the cervix are now undergoing Schauta (radical vaginal) hysterectomy after laparoscopic lymphadenectomy. Patients with carcinoma of the endometrium are treated by laparoscopically assisted vaginal hysterectomy in conjunction with laparoscopic pelvic and para-aortic lymphadenectomy. Staging and second-look procedures are now being performed laparoscopically in patients with carcinoma of the ovary. The Gynecologic Oncology Group is currently investigating the role of laparoscopic surgery for patients with carcinoma of the cervix, endometrium, and ovary in four Phase II trials. A randomized Phase III trial comparing laparoscopy to laparotomy for patients with carcinoma of the endometrium will begin soon.

Laparoscopic surgical staging of ovarian cancer.

The feasibility of laparoscopic staging in patients with ovarian cancer was undertaken prospectively to determine the ability to adequately evaluate both the intraperitoneal cavity and the retroperitoneal lymph nodes. Two groups of ovarian cancer patients were evaluated: those with optimally debulked advanced disease undergoing second-look procedures and those with presumed stage I disease undergoing surgical staging. Twenty-four of the 44 laparoscopic second-look procedures (56%) were positive for persistent disease. Five of these patients had microscopic disease only, in the omentum, washings, pelvic peritoneum, and in para-aortic lymph nodes (2 patients). In the group of 14 patients undergoing staging for presumed early ovarian carcinoma, metastatic disease was discovered in 8 (57%) patients. Two patients had peritoneal washings positive for adenocarcinoma; 3 had pelvic disease, 1 confined to a fallopian tube and 2 to the pelvic peritoneum; and 3 patients had para-aortic lymph nodes positive for metastatic adenocarcinoma. There were no serious complications in this category. The average hospital stay was 1.6 days. Laparoscopic staging appears to be an accurate staging technique, and further investigation into the validity of this approach is warranted.

Laparoscopic lymphadenectomy.

Technical advances in operative laparoscopy are increasing its role in the management of gynecologic malignancies. The feasibility of both para-aortic and pelvic lymphadenectomies, as demonstrated in recent studies, have suggested that complete surgical staging of pelvic malignancies is not far away. We present a review of the progress made to date, and a view of where we need to go.

Laparoscopic hysterectomy for persistent gestational trophoblastic neoplasia.

We performed laparoscopic hysterectomy in a woman with persistent gestational trophoblastic neoplasia. The procedure offered advantages over vaginal hysterectomy in that intraabdominal inspection was possible, morcellation was avoided, and the uterine arteries were transected before uterine manipulation to avoid potential tumor embolization. In addition, an abdominal incision was not required, and the patient had shorter hospitalization and less pain than she would have had with the standard abdominal procedure. Persistent, locally invasive gestational trophoblastic neoplasia (GTN) develops in 15% of women after dilatation and evacuation for molar pregnancy. Chemotherapy and hysterectomy are curative in virtually all patients. Numerous factors are considered in deciding the primary mode of therapy. Women in whom fertility is not an issue may choose hysterectomy, which decreases the amount of chemotherapy required to achieve cure. Traditionally, this has been performed with an abdominal approach. We performed laparoscopic hysterectomy to manage GTN.

Phase II study of 13-cis-retinoic acid plus interferon-alpha 2a in heavily pretreated squamous carcinoma of the cervix.

The combination of 13-cis-retinoic acid (13-cRA) and interferon (IFN)-alpha 2a has been reported to be highly active in previously untreated squamous carcinoma of the cervix. In this phase II study, 13-cRA was given at a dose of 1 mg/kg/day and IFN-alpha 2a was given subcutaneously at a dose of 3 million units/m2/day. Thirteen of 14 patients enrolled in this study are evaluable for response and toxicity. There were no complete or partial responses. Ten patients had progressive disease and the remaining three had stable disease. Principle toxicities were fatigue, nausea, and vomiting. This regimen appears cross-resistant with radiotherapy and/or platinum-based cytotoxic therapy in heavily pretreated patients with squamous carcinoma of the cervix.

Chemoprevention of cervical cancer with folic acid: a phase III Southwest Oncology Group Intergroup study.

Several epidemiological reports and experimental investigations have suggested a preventive role for folic acid in the etiology of cervical cancer. The effect of p.o. folic acid supplementation on the natural history of cervical intraepithelial neoplasia (CIN) was evaluated in a multiinstitutional prospective, randomized, double-blind, placebo-controlled trial. Three hundred thirty-one women with biopsy-proven koilocytic atypia, mild CIN, or moderate CIN were randomized to receive oral folic acid (5 mg) or a similar-appearing placebo daily for 6 months following a 1-month run-in placebo period. Colposcopy, Papanicolaou smear, and serum vitamin levels (folate, retinol, alpha-tocopherol, beta-carotene, and retinyl palmitate) were monitored every 3 months. Demographic, medical, dietary, and sexual history data were obtained from personal interviews. The primary end point of the study was improvement in both Papanicolaou smear and colposcopic picture after 3 and 6 months of treatment as compared to the start of treatment. After 6 months of treatment there was no significant difference between the two study groups in the percentage of patients improved. Median serum folate levels in the treatment arm at 3 and 6 months (29.0 and 20.0 micrograms/dl) were significantly higher than those in the placebo arm (7.8 and 7.1 micrograms/dl, respectively). Mean serum levels of retinol, retinyl palmitate, alpha-tocopherol, and beta-carotene did not differ significantly between the two treatment arms. Our data support the conclusion that supplementation with folic acid (5 mg/day) does not enhance the regression of early epithelial abnormalities of the cervix.(ABSTRACT TRUNCATED AT 250 WORDS)

Spontaneous pneumothorax during operative laparoscopy secondary to congenital diaphragmatic defects. A case report.

As operative laparoscopy increases in popularity and use, so will the number and variety of complications associated with it. Laparoscopists should be cognizant of techniques for avoiding complications as well as alert to conditions that result in complications. We report an operative laparoscopic procedure that resulted in a complete right pneumothorax. This complication developed because of congenital diaphragmatic defects and was recognized and appropriately treated intraoperatively. The combination of the defects with the increased intraperitoneal pressure from laparoscopy resulted in the pneumothorax. The incidental diagnosis of diaphragmatic defects during laparoscopic surgery has not been reported before.