Application of robotic single-site surgery with optional additional port for endometriosis: a single institution's experience.

To evaluate the safety and feasibility of treating stage I-IV endometriosis patients with robotic single-site surgery (RSSS). A retrospective chart review was conducted on 334 patients with endometriosis treated by a single surgeon at a university hospital from January 2015 to November 2019. Surgeries were performed in a single institution between 2015 and 2019. All patients presented with pelvic pain and underwent surgical resection of the lesion. American Society of Reproductive Medicine (ASRM) standards were used to classify endometriosis. The primary goal of this study is to investigate the feasibility and safety of RSSS for surgical resection of stage I-IV endometriosis patients. We will compare patient characteristics and surgical parameters, such as blood loss, operating time, and postoperative complications, across different endometriosis stages to evaluate the effectiveness of this novel technique. RSSS was used for all cases, with no conversions to laparotomy or traditional laparoscopy. One to two additional ports were placed in 41 patients with deeply infiltrating endometriosis (DIE) involving the colorectal and urinary tract and/or extensive pelvic adhesions. Across patient groups, there were no significant differences in age, BMI, fertility history, abdominal surgery history, and hysterectomy ratio (P > 0.05). The median operation time was 140.25 min (range: 85.50-260.00 min, P < 0.05) and median blood loss was 31.25 mL (range: 15-100 mL, P < 0.05). Histopathology supported the diagnosis in 259/334 patients. The undiagnosed patients were associated with lower ASRM scores. For 83.3% of patients (295/334), the length of hospital stay was < 24 h. The postoperative complication rate was 6.0% (20/334), although only two cases were severe. Our results indicate that RSSS is an alternative, safe, and acceptable platform for the surgical treatment of all stages of endometriosis.

Feasibility of two robotic single-site surgery techniques for adolescent endometriosis: Focal versus butterfly.

OBJECTIVE: This study examined the feasibility of robotic laparoendoscopic single-site surgery (LESS) for the treatment of adolescent endometriosis (n = 36). Additionally, we assessed a novel technique known as butterfly resection for severe cases. METHODS: This was a retrospective study of women from 12 to 21 years old who received therapeutic robotic LESS for symptomatic endometriosis by a single experienced surgeon. RESULTS: There were 32 cases of peritoneal and four cases of deep infiltrating endometriosis (DIE). Focal resection was performed in 9/32 peritoneal and all DIE cases; butterfly resection was performed in the remaining 23/32 peritoneal. At 3 months, 16/23 had complete resolution of pelvic pain in the butterfly group versus 10/13 in the focal group (P = 0.64). CONCLUSION: Robotic LESS produces safe outcomes with low complication rates. Butterfly resection may be considered for extensive lesions, with similar levels of pain relief compared to traditional focal resection techniques. CAPSULE: Single-site robotic surgery produces safe outcomes with low complication rates in adolescents with endometriosis, with techniques customized based on disease severity.

Laparoscopic radical hysterectomy with enclosed colpotomy without the use of uterine manipulator for early-stage cervical cancer.

BACKGROUND: We report the application of transuterine suspension sutures (TUSSs) for manipulation and vaginal closure before colpotomy in laparoscopic radical hysterectomy for early-stage cervical cancer. METHODOLOGY: Eight patients with clinical stage IB1 cervical squamous cell cancer were treated with laparoscopic radical hysterectomy between October 2019 and May 2020. The procedure was performed without a traditional uterine manipulator, and the vaginal cuff was closed with a stapler before colpotomy to prevent tumour spillage. RESULTS: All patients successfully underwent the surgery, with a median hospitalisation of 8 days (range 6-14). All drains and urethral catheters were removed after a median of 7 days (range 5-11) and 16 days (range 12-21), respectively. A median of 26 (range 20-32) pelvic lymph nodes were resected and no lymph-related complications were encountered post-operatively. With an enclosed colpotomy, no visible tumour tissues were exposed to the pelvic cavity, and all vaginal stumps healed well without complications. All pathological examinations of the vaginal margin were negative, and there were no residual lesions. At a median follow-up of 6 months, all patients were alive with no recurrence of disease. CONCLUSION: We found that laparoscopic radical hysterectomy with TUSS and vaginal closure before colpotomy is a useful and effective procedure to prevent tumour spillage for the treatment of cervical cancer.

Comparison of Transvaginal and Transumbilical Laparoscopic Single-Site Surgery for Ovarian Cysts.

BACKGROUND: Minimally invasive surgery is currently a preferred treatment for symptomatic ovarian cyst(s), with single-site techniques, such as transumbilical laparoendoscopic single-site surgery (TU-LESS) and transvaginal laparoendoscopic single-site surgery (TV-LESS), gaining increasing popularity. Although both methods have delivered positive outcomes, there is currently limited literature directly comparing TU-LESS and TV-LESS. OBJECTIVES: This study had two primary objectives: (1) to evaluate the safety and feasibility of TV-LESS and TU-LESS for the treatment of ovarian cysts and (2) to compare the surgical and postoperative outcomes of the two procedures. METHOD: This was a prospective observational clinical analysis of 81 patients with a diagnosis of benign ovarian cyst with indication for TV-LESS or TU-LESS. Surgeries were performed at a tertiary hospital between February 1, 2018 and January 31, 2020. Patients were divided into TV-LESS (n = 40) and TU-LESS groups (n = 40), with one excluded due to severe pelvic adhesive disease. Demographics, operation outcomes, and follow-up details were compared. RESULTS: All 80 patients underwent uncomplicated procedures. The two groups were demographically matched (except age), with no difference in operation time, intra-operative blood loss, hemoglobin loss, and hospitalization costs (P > 0.05). However, TV-LESS patients had significantly faster time to ambulation (P < 0.001), faster time to return of bowel function (P < 0.001), less postoperative pain level (P < 0.001), and shorter length of hospital stay (P < 0.001). The cosmetic scores at 1, 4, and 24 weeks after surgery were also higher for the TV-LESS group. CONCLUSION: Our preliminary experience suggested that TU-LESS and TV-LESS are both feasible and safe for ovarian cystectomy and salpingo-oophorectomy. However, TV-LESS may provide three main advantages including: (1) fewer postoperative complications (i.e. incisional hernia); (2) less postoperative pain; and (3) improved cosmetic satisfaction.

A comparison of three approaches for laparoscopic single-site (LESS) myomectomy: conventional, robotic, and hand assisted.

The objective of this study is to determine the feasibility and explore criteria for patient selection for three methods of LESS myomectomy: conventional (C-LESS), robotic-assisted (RA-LESS), and hand-assisted (HA-LESS). This was a retrospective case review of 72 patients with uterine myomas, conducted in a large academic tertiary care hospital between March 1, 2015, and November 7, 2018. LESS myomectomy via conventional, robotic, and hand-assisted routes. 43 patients underwent C-LESS, 15 underwent RA-LESS, and 14 underwent HA-LESS, with no conversions to open abdominal myomectomy. The operative outcomes were compared across the three approaches. The HA-LESS group had the largest mean number (HA: 6.9; C: 3.7; RA: 2.9, P=0.001), diameter (HA: 11.3 cm; C: 9.3 cm; RA: 7.1 cm, P=0.035), and weight (HA: 850.1 g; C: 320.7 g; RA: 181.1 g, P=0.003) of myomas removed per patient. The use of this method was also found to have a direct correlation with estimated preoperative uterine size (HA: 20.1 weeks; C: 16.2 weeks; RA: 12.0 weeks, P=0.001. Operative time and postoperative stay were found to be not statistically different across groups. We conclude that all three types of LESS myomectomy are feasible with comparable surgical outcomes. Most importantly, our findings indicate that hand assistance can be combined with C-LESS myomectomy for large or multi-fibroid uterus without compromising operating time or patient recovery. Notably, we found that uterine size could be a useful tool for the determination of the surgical approach.

Laparoendoscopic single-site inguinal lymphadenectomy in gynecology: preliminary experience at a single institution.

PURPOSE: Laparoendoscopic single-site surgery (LESS), a promising innovation in minimally invasive surgery, has been used in treating gynecologic oncology diseases. There have been no reports in the literature regarding LESS for inguinal lymphadenectomy (LESS-IL) in gynecologic conditions. We aimed to evaluate the feasibility, safety, and outcomes of LESS-IL. METHODS: Six patients with vulvar or vaginal cancer underwent LESS-IL from July 2018 to March 2019. Data regarding the intraoperative and postoperative outcomes were analyzed. RESULTS: All patients successfully underwent a bilateral LESS-IL without conversion. LESS pelvic lymphadenectomy via an umbilical incision was also performed in a patient with vaginal cancer. The median operation time for the single-port laparoendoscopic inguinal lymphadenectomies was 105 min (range 70-134), with a median estimated blood loss of 108 ml (range 40-170). Median time of hospitalization was 7.5 days (range 5-10). A median of 11 (6-15) lymph nodes were dissected in a unilateral groin. The suction drains were removed after a median duration of 5 days (range 3-7). There were no skin-related or lymph-related postoperative complications. At a median follow-up period of 9 months, all the patients were alive and no recurrence was found. CONCLUSION: LESS-IL is a feasible and safe technique for the surgical management of gynecologic cancers.

Pregnancy-preserving Laparoendoscopic Single-site Surgery for Gynecologic Disease: A Case Series.

STUDY OBJECTIVE: The study objective was to assess the feasibility of laparoendoscopic single-site surgery (LESS) for the management of nonobstetric, gynecologic disease processes in pregnant patients. DESIGN: A retrospective case series of 13 pregnant women aged 21 to 42 years who underwent LESS for various gynecologic pathology. If able to be contacted, the patients were followed up until the delivery of the fetus. SETTING: The surgeries were performed in a single institution between January 2015 and June 2019. PATIENTS: The patients were selected if a laparoscopic intervention was indicated. INTERVENTIONS: The cases included 6 ovarian cystectomies and 2 salpingo-oophorectomies for adnexal masses; 1 myomectomy for a degenerated myoma; 1 salpingectomy for a heterotopic pregnancy; 2 cerclage placements for recurrent pregnancy loss and cervical insufficiency; and 1 paratubal cystectomy. The patients underwent LESS through a 2.5-cm umbilical incision. The masses were exteriorized using a laparoscopic specimen retrieval bag, with the exception of 2 large adnexal masses, which were aspirated at the incision site, exteriorized after content drainage, and cystectomies performed extracorporeally. The fascial incision was repaired with a permanent suture. MEASUREMENTS AND MAIN RESULTS: Various data were collected from patients, including age, surgical and obstetric history, gestational age at surgery, and ultrasonic imaging results. The outcomes measured were operative duration, intraoperative bleeding, postoperative symptoms, fetal monitoring before and after surgery, pathologic findings, conversions, intraoperative complications, and pregnancy outcomes. Eight cases were performed in the first trimester, 4 in the second trimester, and 1 in the third trimester, with the surgeries lasting between 45 minutes and 298 minutes. The blood loss ranged from 5 mL to 300 mL, and postoperative symptoms of mild pelvic or abdominal pain were reported. There were 2 conversions to traditional multiport laparoscopic surgery for the 2 cerclage cases, and there were no open surgery conversions or intraoperative complications. The fetal heart rate ranged between 130 beats per minute and 167 beats per minute postoperatively. Of the 9 patients who were able to be contacted for follow-up, all had successful deliveries. One patient was healthy at 31 weeks and 5 days without complication at the time of her last follow-up. CONCLUSION: LESS may be performed by experienced surgeons on gravid patients in any trimester for adnexal masses, myomas, heterotopic pregnancy, and cervical incompetence. Future multiple-center studies may provide further evidence that LESS is a feasible and safe option for gynecologic surgery during pregnancy.

Unclassified unilateral persistent sciatic artery in a patient with chronic intermittent claudication.

Patients with persistent sciatic artery are at high risk for development of limb ischemia, aneurysm formation, and embolism. In this report, we identify a nonclassified left leg persistent sciatic artery in a patient with chronic limb ischemia. Vascular reconstruction was carried out by common iliac-deep femoral artery bypass to restore adequate arterial flow. Our approach to placement of the distal anastomosis on the deep femoral artery instead of on the popliteal artery, which is used in routine practice, may potentially increase treatment efficacy and decrease surgical complications. At 2-year follow-up, the patient remained asymptomatic and in good health.

Effects of Beneficial Mutations in pykF Gene Vary over Time and across Replicate Populations in a Long-Term Experiment with Bacteria.

The fitness effects of mutations can depend on the genetic backgrounds in which they occur and thereby influence future opportunities for evolving populations. In particular, mutations that fix in a population might change the selective benefit of subsequent mutations, giving rise to historical contingency. We examine these effects by focusing on mutations in a key metabolic gene, pykF, that arose independently early in the history of 12 Escherichia coli populations during a long-term evolution experiment. Eight different evolved nonsynonymous mutations conferred similar fitness benefits of ∼10% when transferred into the ancestor, and these benefits were greater than the one conferred by a deletion mutation. In contrast, the same mutations had highly variable fitness effects, ranging from ∼0% to 25%, in evolved clones isolated from the populations at 20,000 generations. Two mutations that were moved into these evolved clones conferred similar fitness effects in a given clone, but different effects between the clones, indicating epistatic interactions between the evolved pykF alleles and the other mutations that had accumulated in each evolved clone. We also measured the fitness effects of six evolved pykF alleles in the same populations in which they had fixed, but at seven time points between 0 and 50,000 generations. Variation in fitness effects was high at intermediate time points, and declined to a low level at 50,000 generations, when the mean fitness effect was lowest. Our results demonstrate the importance of genetic context in determining the fitness effects of different beneficial mutations even within the same gene.

Prostacyclin administration as a beneficial supplement to the conventional cancer chemotherapy.

Prostacyclin (PGI(2)) and its analogues protect from cardiovascular disease through pleiotropic effects such as vasodilation, inhibition of platelet aggregation, leukocyte adhesion, and vascular smooth muscle cell (VSMC) proliferation. Additionally, prostacyclin synthase (PGIS) and PGI(2) also possess anti-cancer properties. As of late (2009-2010), numerous studies have identified the deleterious side-effects of chemotherapy on the cardiovascular system, which have been deemed as a serious clinical issue. Cardiomyocyte damage, induced by oxidative stress, is one of the clinical consequences caused by routine cancer chemotherapy. Previous studies indicate iloprost, a PGI(2) analogue, can protect against doxorubicin-induced (DOX) cardiomyocyte injury in vitro and in vivo without compromising tumor suppression. Therefore, we hypothesize PGI(2) can be used as a cardioprotective supplement to attenuate the damaging cardiac effects caused by the traditional cancer chemotherapy regimen.