Robot-Assisted Hysterectomy Using the Double-Bipolar Method.

OBJECTIVE: To demonstrate the efficacy of the double-bipolar method in a benign hysterectomy. DESIGN: Stepwise demonstration of the technique with a narrative video. SETTING: The double-bipolar method was first reported in 2011 [1] and is gaining popularity in Japan; however, its usefulness in robot-assisted hysterectomy is under-reported. When unexpected bleeding occurs during robot-assisted hysterectomy using a monopolar technique, corrective measures may be prolonged and often require changing forceps. The Maryland forceps have 4 functions, including incision, dissection, grasping, and coagulation, which enable rapid responses to bleeding and reduce forceps changes and cost. Previously, we reported the usefulness of the double-bipolar technique in other surgical procedures [2,3]. Herein, we present a case of robot-assisted hysterectomy using this technique at an urban general hospital, including detailed insights into its execution. INTERVENTIONS: A 45-year-old female patient presented to our hospital with painful menstrual bleeding. Magnetic resonance imaging revealed an 8-cm myoma in the posterior wall of the uterine cervix. Consequently, a robot-assisted hysterectomy was performed using right-handed Maryland forceps (Intuitive, Sunnyvale, CA) and the ForceTriadTM Energy Platform (Medtronic, Minneapolis, MN) in the macro mode, with an output of 60 W. This configuration ensured a consistent electronic output, regardless of the electrical resistivity of the target tissues, facilitating precise incisions using a momentary high voltage [4]. The surgical duration was 60 minutes, and the estimated blood loss was 5 mL. CONCLUSION: The highly versatile double-bipolar method uses one forceps for incision, dissection, coagulation, and grasping and is useful in gynecological surgery. VIDEO ABSTRACT.

Extraovarian Dysgerminoma Involving the Uterine Cervix: A Rare Case Report With Literature Review.

Primary extraovarian dysgerminoma (EOD) is a very rare disease. There is no literature about primary EOD involving the uterine cervix. We herein present details of a unique case of primary EOD involving the uterine cervix. A 46-year-old woman with uterine cervical tumor was referred to our institution with atypical genital bleeding. A polypoid tumor localized to the uterine cervix was found. Cervical biopsy detected malignant components of likely nonepithelial cell origin. Preoperative imaging examinations showed a uterine cervical tumor measuring ~5 cm, suggestive of malignancy without distant or lymph node metastases. The patient underwent abdominal radical hysterectomy with pelvic lymph node dissection according to the standard treatment for stage IB3 cervical cancers. The pathological diagnosis was dysgerminoma involving the uterine cervix and the right fallopian tube. Immunohistochemical results were as follows: SALL4 (+), octamer-binding transcription factor 4 (+), D2-40 (+), and c-Kit (+). She received 3 cycles of adjuvant chemotherapy with bleomycin, etoposide, and cisplatin. The disease did not recur up to 14 months after surgery. This is the first-ever published case of primary EOD involving the uterine cervix among previously reported EOD cases. Reported cases of EOD in female genital tract are also reviewed. Our case provides more extensive insights for pathologists to consider the differential diagnosis of cervical lesions. In our case, combination therapy involving a surgical approach-according to cervical cancers and adjuvant chemotherapy as used for ovarian dysgerminomas-was effective. Future verification is needed regarding the best approach for treating uterine cervical dysgerminomas.

Robot-assisted Exploration of Somatic Nerves in the Pelvis and Transection of the Sacrospinous Ligament for Alcock Canal Syndrome.

STUDY OBJECTIVE: Some articles have reported the surgical management of Alcock canal syndrome (ACS) using the transperineal [1], transgluteal [2], or conventional laparoscopic approach [3,4]. In 2015, Rey and Oderda [5] reported the first robotic neurolysis of the pudendum, providing the advantages of robot-assisted surgery: magnified and 3-dimensional vision and greater precision of movements. However, to our knowledge, there have been no reports on the use of a robotic platform for the treatment of ACS in the field of gynecology. Therefore, the objective of this video is to describe the anatomic and technical highlights of robotic exploration of the somatic nerves in the pelvis and transection of the sacrospinous ligament (nerve decompression) for ACS. DESIGN: Stepwise demonstration of the technique with narrated video footage. SETTING: An urban general hospital. A 48-year-old woman who had no previous surgical history was referred for severe pain when sitting, cyclic pelvic pain, and gluteal and perineal pain, all of which were resistant to medication therapy. Her pain radiated to the posterior aspect of the thigh. Before coming to our hospital, she visited an orthopedic surgeon a few years earlier and was diagnosed with sciatic neuralgia. Magnetic resonance imaging revealed adenomyosis with neither deep endometriosis nor vascular entrapment. On the basis of neuropelveologic evaluation, the patient was suspected to be suffering from ACS owing to compression of the pudendal nerve and the posterior cutaneous nerve of the thigh by the sacrospinous ligament. INTERVENTIONS: The procedure was performed using the following 9 steps while referencing the laparoscopic neuronavigation technique [6]: step 1, opening the peritoneum along the external iliac artery; step 2, exposure of the external iliac artery; step 3, development of the lumbosacral space; step 4, identification of the lumbosacral trunk; step 5, identification of the superior gluteal nerve; step 6, identification of the sciatic nerve; step 7, identification of the inferior gluteal nerve; step 8, identification of the pudendal nerve; and step 9, transection of the sacrospinous ligament. The surgery was completed successfully without any complications, and the postoperative course was uneventful. We considered that there was no relationship between the ACS and endometriosis. The patient reported that her pain decreased gradually at postoperative month 1 and month 3, and finally the neuralgia was completely resolved at month 6. Neuropelveologic evaluation still continues every 6 months. CONCLUSION: Robot-assisted transection of the sacrospinous ligament is a feasible, safe technique for selected patients with ACS. Exploration of the pelvic nerves should be performed for further diagnosis and therapy before prematurely labeling the patient as refractory to the treatment [7].

Rate of recurrent hydronephrosis after laparoscopic ureteroneocystostomy for ureteral endometriosis.

STUDY OBJECTIVE: To investigate the short-term outcomes of laparoscopic ureteroneocystostomy in patients with ureteral endometriosis (UE). DESIGN: Retrospective cohort study of consecutive patients who underwent surgery for the ureter endometriosis with hydronephrosis. SETTING: A private hospital that provide primary, secondary and tertiary care. PATIENTS: 30 consecutive patients with UE who underwent laparoscopic ureteroneocystostomy at our institution between May 2008 and April 2020. INTERVENTIONS: Laparoscopic ureteroneocystostomy, if necessary, hysterectomy, salpingo-oophorectomy, cystectomy, partial bladder resection, or partial bowel resection were performed. MEASUREMENTS AND MAIN RESULTS: The most common chief complaint was pelvic pain (40%). Endometriosis affected only the left ureter in 56.7% of patients, only the right ureter in 33.3%, and both ureters in 6.7%. Involvement of the ipsilateral ovary was confirmed in 64.3%. The most frequent location of UE was 1-3 cm above the UVJ (46.7%). A psoas hitch was performed in 7 patients (23.3%), and the Boari flap was used in 9 patients (30%). Hysterectomy was performed in 12 patients (40%), and 6 of them had a concomitant bilateral salpingo-oophorectomy (20%). In addition, 3 patients (10%) underwent partial bowel resection, and 2 patients (6.7%) underwent partial bladder resection. After surgery, 24 of 27 patients (80.0%) were free of sever hydronephrosis after surgery. Hydronephrosis recurred in a single patient (3.3%), but the grade of hydronephrosis improved significantly after surgery (P < 0.001). At 6 months of follow up, 4 patients (13.3%) experienced urinary tract infections and 2 patients (6.7%) reported dysuria. Patients reported a regression of dysmenorrhea symptoms (P < 0.001). CONCLUSION: This study shows that ureteroneocystostomy provides good results in terms of relapses and symptom control in patients with ureteral endometriosis.

Fertility- and Nerve-sparing Laparoscopic Eradication of Deep Endometriosis with Total Posterior Compartment Peritonectomy: The Kurashiki Method.

OBJECTIVE: To show technical highlights of a nerve-sparing laparoscopic eradication of deep endometriosis (DE) with posterior compartment peritonectomy. DESIGN: Demonstration of the technique with narrated video footage. SETTING: An urban general hospital. A systematic review and meta-analysis has suggested significant advantages of the nerve-sparing technique when considering the relative risk of persistent urinary retention in the treatment of DE [1]. In addition, a recent article has suggested that complete excision of DE with posterior compartment peritonectomy could be the surgical treatment of choice to decrease postoperative pain, improve fertility rate, and prevent future recurrence [2]. However, in DE, nerve-sparing procedures are even more challenging than oncologic radical procedures because the pathology resembles both ovarian/rectal cancer in terms of visceral involvement and advanced cervical cancer in terms of wide parametrial infiltration through the pelvic wall. INTERVENTIONS: The video highlights the anatomic and technical aspects of a fertility- and nerve-sparing surgery in DE with posterior compartment peritonectomy. After adhesiolysis and ovarian surgery, we developed retroperitoneal space at the level of promontory. The hypogastric nerve consists of the upper edge of the pelvic plexus, therefore the autonomic nerves were separated in a "nerve plane" by sharp interfascial dissection of the loose connective tissue layers both above (between the fascia propria of the rectum and the prehypogastric nerve fascia) and below (between the prehypogastric nerve fascia and the presacral fascia) the hypogastric nerve [3,4]. As a result of these dissections, the autonomic nerves in the pelvis were separated like a sheet with surrounding fascia. We then completely resected all DE lesions including peritoneal endometriosis while avoiding injury to the nerve plane. In a small number of our experiences, none of the patients (n = 51) required clean intermittent self-catheterization after this procedure. CONCLUSION: Fertility- and nerve-sparing laparoscopic eradication of DE with total posterior compartment peritonectomy is a feasible technique and may provide both curability of DE and functional preservation. Our nerve-sparing technique can reproducibly simplify this complex procedure.

Robot-assisted Nerve Plane-sparing Eradication of Deep Endometriosis with Double-bipolar Method.

OBJECTIVE: To demonstrate anatomic and technical highlights of a robot-assisted nerve plane-sparing eradication of deep endometriosis (DE). DESIGN: Stepwise demonstration of the technique with narrated video footage. SETTING: An urban general hospital. INTERVENTIONS: Laparoscopic nerve-sparing techniques as represented by the Negrar method reportedly result in lower rates of postoperative bladder, rectal, and sexual dysfunctions than classical approaches [1]. In addition, robotic surgery has become available, and 2 meta-analyses have confirmed that robotic surgery is safe and feasible for the treatment of endometriosis, especially in advanced cases [2,3]. However, few papers have shown the surgical techniques for a nerve-sparing procedure using a robotic approach. The patient was a 45-year-old woman who presented with severe chronic pelvic pain and dysmenorrhea resistant to medication therapy. She had no nerve-specific complaints such as pain in the pudendal distribution or a voiding dysfunction. Magnetic resonance imaging revealed multiple uterine fibromas and adenomyosis with DE, involving the uterosacral ligament and surface of the rectum, with cul-de-sac obliteration. The parametrium was not involved in the DE. Robot-assisted nerve plane-sparing excision of DE with a double-bipolar method was performed using the following 8 steps: step 1, adhesiolysis and adnexal surgery; step 2, checking the ureteral course; step 3, separation of the nerve plane (step 3.1, dissection of the avascular layer below the hypogastric nerve, between the prehypogastric nerve fascia and presacral fascia; and step 3.2, dissection of the avascular layer above the hypogastric nerve, between the prehypogastric nerve fascia and fascia propria of the rectum) [4,5]; step 4, reopening of the pouch of Douglas; step 5, complete removal of DE lesions while avoiding injury to the nerve plane; step 6, hysterectomy (if the patient desires non-fertility-sparing surgery); step 7, checking for rectal injury using an air leakage test; and step 8, barrier agents for adhesion prevention. With regard to step 3, as a result of sharp dissection between avascular layers both above and below the hypogastric nerve, autonomic nerves in the pelvis were separated like a sheet with the surrounding fascia (the nerve plane). We then performed steps 4 to 6 in a step-by-step manner while avoiding injury to the nerve plane. The urinary catheter was removed within 24 hours after the surgery, and no residual urine was seen. The patient developed no perioperative complications; in particular, no postoperative bladder or rectal dysfunctions. The precise sharp dissection of the right embryo-anatomic planes on the basis of the detailed mesoanatomy seems important for improving functional outcomes in nerve-sparing surgery [5]. CONCLUSION: Robot-assisted nerve plane-sparing eradication of DE is as technically feasible as the conventional laparoscopic approach. The step-by-step technique should help surgeons perform each part of the surgery in a logical sequence, making the procedure easier and safer to complete. However, the latent benefits of robot-assisted nerve-sparing surgery in the treatment of DE remain uncertain.

Peutz-Jeghers syndrome complicated by gastric-type cervical mucinous carcinoma and primary peritoneal carcinoma.

A 45-year-old multiparous woman with a STK11 mutation and a history of Peutz-Jeghers syndrome underwent radical hysterectomy and bilateral salpingo-oophorectomy for a gastric-type cervical mucinous carcinoma. Four and a half years later, blood tests revealed elevations in CEA and CA125 tumor marker levels, and computed tomography showed multiple calcifications in the peritoneum. Peritoneal dissemination was suspected, and a laparoscopic biopsy was performed. Histopathology showed a high-grade serous carcinoma, and the patient was diagnosed with a metachronous stage IIIC primary peritoneal carcinoma. She had no BRCA1/2 mutation. After chemotherapy with docetaxel, carboplatin, and bevacizumab, she achieved complete remission.

Short-term outcomes of robot-assisted versus conventional laparoscopic surgery for early-stage endometrial cancer: A retrospective, single-center study.

AIM: We compared the short-term outcomes between conventional laparoscopic surgery (CLS) and robot-assisted surgery (RAS) to assess the technical feasibility of the latter for early-stage endometrial cancer. METHODS: We retrospectively compared the perioperative outcomes between two groups of 223 patients (CLS group, n = 102; RAS group, n = 121) with early-stage endometrial cancer. Surgical procedures included hysterectomy, bilateral salpingo-oophorectomy and retroperitoneal lymphadenectomy. We analyzed the data from intrapelvic surgery alone because para-aortic lymphadenectomy was performed via conventional endoscopic extraperitoneal approach without robot for both groups. RESULTS: No differences were identified in patients' age and body mass index. The mean operative time was 133 ± 28 versus 178 ± 41 min (P < 0.01), mean blood loss was 196 ± 153 versus 237 ± 146 mL (P = 0.047), mean length of postoperative hospital stay was 9 ± 4 versus 8 ± 3 days (P = 0.01) and mean rate of perioperative complications of Clavien-Dindo grade III or higher was 2.0 versus 3.4% (P = 0.53) for the CLS versus RAS groups, respectively. There was no significant difference in the number of resected lymph nodes. CONCLUSION: The operative time was significantly longer and blood loss was significantly greater in the RAS group than in the CLS group, without a significant difference in the number of resected lymph nodes. These differences are within an acceptable clinical range, showing that RAS is feasible and safe for early-stage endometrial cancer, providing short-term outcomes comparable to those of conventional surgery. Future studies are warranted to compare the long-term oncological outcomes by extending the observation period and including para-aortic lymphadenectomy data.

Short-term outcomes of robotic-assisted versus conventional laparoscopic radical hysterectomy for early-stage cervical cancer: A single-center study.

AIM: Our hospital adopted laparoscopic surgery for early-stage cervical cancer in August 1998, with robot-assisted surgery implemented in October 2013. This study aimed to compare short-term outcomes for conventional laparoscopic radical hysterectomy (LRH) and robot-assisted radical hysterectomy (RARH) and assess the technical feasibility of RARH for early-stage cervical cancer. METHODS: We retrospectively compared operative time, blood loss, number of resected lymph nodes, length of postoperative hospital stay, rate of positive vaginal margin and perioperative complications between two groups of 121 patients (LRH group, n = 57; RARH group, n = 64) with stage IA2 to IIB, among 164 patients who underwent endoscopic radical hysterectomy for early-stage cervical cancer performed between January 2010 and December 2017 by an expert surgeon, excluding cases of para-aortic lymphadenectomy. RESULTS: No differences in patient background, in terms of age and body mass index, were identified. For the LRH/RARH groups (mean ± standard deviation), results obtained were as follows: operative time, 211 ± 38/280 ± 59 min (P < 0.01); blood loss, 219 ± 114/370 ± 231 mL (P < 0.01); number of resected lymph nodes, 38.5 ± 15.9/50.2 ± 18.2 (P < 0.01); length of postoperative hospital stay, 11.6 ± 3.3/11.3 ± 4.8 days (P = 0.67); and perioperative complications with Clavien-Dindo classification of grade III or higher, 1.8/7.8% (P = 0.13). CONCLUSION: The operative time was significantly longer and blood loss greater in the RARH than LRH group. A greater number of lymph nodes were removed in the RARH group. However, these differences seem to be within a clinically acceptable range, showing that RARH is as feasible and safe as LRH in terms of short-term outcomes.

Long-term oncological outcomes of minimally invasive radical hysterectomy for early-stage cervical cancer: A retrospective, single-institutional study in the wake of the LACC trial.

AIM: The objective of this study was to investigate the long-term oncological outcomes of minimally invasive radical hysterectomy (MIRH) for the treatment of early-stage cervical cancer retrospectively in the wake of the laparoscopic approach to cervical cancer (LACC) trial. METHODS: A total of 109 patients with stage IA1 with lymphovascular space involvement, IA2, and IB1 cervical cancers were included in this study. The surgical and oncological outcomes were retrospectively evaluated. All patients underwent type C MIRH with a no-touch isolation technique for cervical tumor. RESULTS: The median number of resected pelvic lymph nodes was 36 (range, 14-94), and 10 patients (9.2%) had positive nodes. One patient (0.9%) had positive surgical margins. Forty-six patients (42%) underwent adjuvant therapy. The median follow-up time was 73 months (range, 30-146 months). Five patients (4.6%) developed recurrent disease, and 3 patients (2.8%) died of cervical cancer. The 5-year disease-free survival and overall survival rates were 96.3% and 97.2%, respectively. A comparison between patients with tumor diameter ≤ 2 cm (n = 59) and those with tumor diameter > 2 cm (n = 50) did not identify any significant differences, with 5-year disease-free survival 96.6% versus 94.0% and 5-year overall survival 98.3% versus 96.0%, respectively. CONCLUSION: In this retrospective study, MIRH with a no-touch isolation technique for stage IA to IB1 cervical cancer was a safe approach in terms of oncological outcomes. However, every surgeon who treats early-stage cervical cancer should inform each patient of the results of the LACC trial because it has an exceedingly high impact.

Extraperitoneal Endoscopic Total Retroperitoneal Lymphadenectomy: No Bowel Surgery.

STUDY OBJECTIVE: We describe our ultra-minimally invasive retroperitoneal lymphadenectomy using the extraperitoneal approach. This technique was developed to make traditionally invasive oncologic surgery more patient friendly and safer by eliminating the bowel from the operative field. DESIGN: Description of a surgical technique. Canadian Task Force II-3. SETTING: Urban general hospital in Japan. PATIENTS: 320 Women undergoing endoscopic extraperitoneal paraaortic and pelvic lymphadenectomy for endometrial cancer from Jan 2001 to Dec 2013. INTERVENTIONS: Patients underwent endoscopic extraperitoneal para-aortic and pelvic lymphadenectomy for endometrial cancer. We accessed the retroperitoneal space with a visual access cannula (Endotip). This device easily facilitates peritoneal tenting. After expanding the extraperitoneal space by blunt dissection with forceps, carbon dioxide was infused. The upper limit of our dissection was the renal vein and the lower limit was the iliac circumflex vein. The extraperitoneal approach naturally creates a bowel-free operative field, even when dissecting in the pelvis. This approach only requires a 5-mm access hole, making it the least invasive approach to this kind of surgery. MEASUREMENTS AND MAIN RESULTS: The 5-year survival rates for this intervention combined with hysterectomy and bilateral adnexectomy are extremely favorable at 90% for patients with stage I to III disease, making this technique a viable minimally invasive approach for selected patients. CONCLUSION: We can achieve a total para-aortic and pelvic retroperitoneal dissection with this extraperitoneal approach without the bowel invading the operative field. This procedure is focused on the barrier-free nature of working in the retroperitoneal space, meaning a space that is not hindered by the invasion of the bowel or other intraperitoneal structures.

Total laparoscopic nerve-sparing radical parametrectomy for occult early-stage cervical cancer: surgical technique and postoperative bladder function.

Surgery and radiotherapy are both regarded as standard treatments for occult cervical cancers. Surgery has several theoretical advantages over radiotherapy; therefore, such cancers, especially in their early stages, are commonly treated with radical parametrectomy. However, postoperative bladder dysfunction is an important potential complication of this type of surgery. This is a case report of total laparoscopic nerve-sparing radical parametrectomy for an occult cervical cancer using our original surgical concept based on detailed anatomical investigation of pelvic nerve networks in a fresh cadaver. We evaluated the validity of our nerve-sparing technique by assessing postoperative bladder function using urodynamic studies.

Robot-Assisted versus Laparoscopic Surgery for Pelvic Lymph Node Dissection in Patients with Gynecologic Malignancies.

Objectives: The objective of this study was to compare the surgical outcomes for pelvic lymph node dissection (PLND) performed through conventional laparoscopic surgery (CLS) versus robot-assisted surgery (RAS) in patients with gynecologic malignancies. Materials and Methods: Perioperative data, including operative time, estimated blood loss, and complications, were retrospectively analyzed in 731 patients with gynecologic malignancies who underwent transperitoneal PLND, including 460 and 271 in the CLS and RAS groups, respectively. Data were statistically analyzed using the Chi-square test or Student's t-test as appropriate. P < 0.05 was considered statistically significant. Results: The mean age was 50 ± 14 years and 53 ± 13 years in the RAS and CLS groups (P < 0.01), respectively. The mean body mass index was 23.4 ± 4.8 kg/m2 and 22.4 ± 3.6 kg/m2 in the RAS group and CLS groups (P < 0.01), respectively. The operative time, blood loss, and number of resected lymph nodes were 52 ± 15 min, 110 ± 88 mL, and 45 ± 17, respectively, in the RAS group and 46 ± 15 min, 89 ± 78 mL, and 38 ± 16, respectively, in the CLS group (all P < 0.01). The rate of Clavien-Dindo Grade ≥ III complications was 6.3% and 8.7% in the RAS and CLS groups, respectively (P = 0.17). Conclusion: Shorter operative time and lower blood loss are achieved when PLND for gynecologic malignancies is performed through CLS rather than RAS. However, RAS results in the resection of a greater number of pelvic lymph nodes.

Effect of Uterine Weight on the Surgical Outcomes of Robot-Assisted Hysterectomy in Benign Indications.

Background Uterine weight is an important factor in determining the complexity of a hysterectomy. Although greater uterine weight increases operative time and blood loss in open or laparoscopic surgery, it remains uncertain whether this applies to robot-assisted hysterectomy. This study aimed to investigate the effect of uterine weight on the surgical outcomes of robot-assisted hysterectomy. Methods We conducted a retrospective cohort study involving 872 patients who underwent robot-assisted hysterectomies at our institution between January 2019 and June 2022. Of these, 724 cases were analyzed and classified into four groups based on uterine weight: <250 g (377 patients), 250-500 g (253 patients), 500-750 g (69 patients), and ≥750 g (25 patients). We performed univariate analysis with the following endpoints: operation time, blood loss, postoperative hospital stay, complication rate, conversion to laparotomy rate, and blood transfusion rate. Results Operating time and blood loss increased significantly with greater uterine weight in the four groups (both p-values <0.01), but postoperative hospital stay and complication rate did not increase (p = 0.448, p = 0.679, respectively). None of the patients underwent conversion to laparotomy or blood transfusion. Conclusion Although the operating time for robot-assisted hysterectomy and blood loss increased with greater uterine weight, the complications and length of postoperative hospital stay were similar between groups. Robot-assisted hysterectomy is safe in cases of much uterine weight.

Surgical training in extraperitoneal laparoscopic para­aortic lymphadenectomy for the treatment of gynecological cancer using a Thiel­embalmed cadaver.

The extraperitoneal laparoscopic approach (ELPAN) for para-aortic lymphadenectomy provides excellent visibility of the left side of the aorta, thus facilitating surgery in the retroperitoneal space. This technique is highly complex compared with the transperitoneal approach. In particular, advanced techniques are required to develop an appropriate surgical field in the narrow retroperitoneal space; therefore, surgeons need to undergo a significant amount of training to become competent. A variety of tools are available for surgical training but are limited by their ability to reproduce complex anatomy. Thus, cadavers may represent the most suitable tool for learning this unique technique. The present study describes a surgical training protocol for the ELPAN technique using a Thiel-embalmed human cadaver and provides a step-by-step description of the ELPAN technique performed at Okayama University (Okayama, Japan). A 72-year-old Thiel-embalmed female cadaver was used to develop a protocol for surgical training in the ELPAN technique that effectively reproduced the methodology required in clinical practice. A training method for ELPAN surgery was developed and successfully completed using the Thiel-embalmed cadaver that secured the surgical field in the retroperitoneal space and permitted resection of the lymph nodes. The Thiel-embalmed cadaver tissue possessed excellent properties for surgical training, including color tone, flexibility, and the membrane structure of connective and fat tissues. In addition, this method of fixation preserved stiffness and elasticity of the peritoneum, although large vessels were slightly fragile and poorly extensible. Surgical training using a Thiel-embalmed human cadaver represents a valuable option for learning the ELPAN surgical technique. However, this technique may be unsuitable for training in perivenous manipulation. To the best of our knowledge, this is the first report to describe the use of Thiel-embalmed cadavers as a tool for surgeons to undergo training in the ELPAN technique.

Obstetric outcomes of patients undergoing total laparoscopic radical trachelectomy for early stage cervical cancer.

OBJECTIVE: To assess the obstetric outcomes of our total laparoscopic radical trachelectomy (TLRT) cases for early stage cervical cancer. MATERIALS AND METHODS: A total of 56 patients who underwent TLRT between December 2001 and August 2012 were reviewed retrospectively using clinicopathological, surgical, and follow-up data from patients' medical records. RESULTS: We performed this operation on 56 patients during the study period. The mean age of these 56 patients was 31.9 years (range 22-42 years). Fifty-three patients' fertility was preserved without requiring post-operative adjuvant treatment. Twenty-five women attempted to conceive, of whom 13 succeeded for a total of 21 pregnancies (52% pregnancy rate). Ten of these 21 pregnancies were the result of assisted reproductive technologies. Of those, 5 resulted in first trimester miscarriages, 2 in second trimester miscarriages, and 13 in live births. Ten pregnancies reached the third trimester. Preterm premature rupture of membranes (8/13, 61.5%) was the most common complication during pregnancy. The rate of preterm delivery was 47.6%. Three patients delivered at 22-28 weeks of gestational age. Two of these babies showed permanent damage: one has cerebral palsy; the other has developmental retardation. One pregnancy is ongoing. CONCLUSION: TLRT is a useful technique associated with an excellent pregnancy rate in fertility-preserving surgery to treat early stage cervical cancer.

Laparoscopic adnexectomy with peritonectomy for an ovarian tumor adhered to the pelvic sidewall.

Laparoscopic adnexectomy is one of the most commonly used surgical techniques for the treatment of ovarian tumor. However, many physicians find it difficult to conduct the resection without rupturing the ovarian tumor, especially in cases with tumor adhesions. In the case we are presenting, we unexpectedly encountered an ovarian tumor adherent to the pelvic sidewall. Because the possibility of a malignancy could not be completely excluded, we decided to concomitantly resect the ovary and its adherent peritoneum, to avoid any potential tumor rupture due to its manipulation. We were successfully able to laparoscopically retrieve the intact ovarian tumor, without its rupture. The pathological diagnosis was of a Grade 2, FIGO stage IIb endometrioid adenocarcinoma of both ovaries. As a result of this diagnosis, we performed a comprehensive staging laparoscopy. Following the completion of adjuvant chemotherapy, the patient has showed no signs of recurrent malignancy after 3 years. This case report describes our technique for the surgical management of an ovarian tumor adherent to the pelvic wall. To avoid spillage of the tumor contents, the simultaneous resection of the tumor with its adhered peritoneum is a useful method to consider.