Scar-Free Laparoscopy in BRCA-Mutated Women.

Background and Objectives: BRCA 1 and 2 mutations have a cumulative risk of developing ovarian cancer at 70 years of 41% and 15%, respectively, while a cumulative risk of breast cancer by 80 years of age was 72% for BRCA1 mutation carriers and 69% for BRCA2 mutation carriers. The NCCN recommends risk-reducing salpingo-oophorectomy (RRSO), typically between 35 and 40 years, and upon completion of childbearing in BRCA1 mutation, while it is reasonable to delay RRSO for management of ovarian cancer risk until age 40-45 years in patients with BRCA2. In recent years there have been two main lines of evolution in laparoscopy. The former concerning the development of a single-site laparoscopic and the latter concerning the miniaturisation of laparoscopic instruments (mini/micro-laparoscopy). Materials and Methods: In this case report, we show our experience in prophylactic adnexectomy, on a mutated-BRCA patient, using the MiniLap® percutaneous surgical system. Results: This type of technique is safe and effective and does not require a particular learning curve compared to single-port laparoscopy. Conclusions: The considerable aesthetic advantage of the scars, we believe, albeit to a lesser extent, is useful to find in these patients burdened by an important stress load.

Robotic surgery vs laparoscopic surgery in patients with diagnosis of endometriosis: a systematic review and meta-analysis.

Endometriosis is one of the most common medical conditions affecting the women. The study aimed to evaluate the safety and efficacy of robotic-assisted laparoscopic surgery (RAS) versus conventional laparoscopic surgery (LPS) in the treatment of endometriosis. PubMed, Embase, Cochrane and CINAHL databases were searched from January 1995 to March 2019. According to meta-analysis criteria, five comparative studies were selected. A total of 1527 patients were identified. In the meta-analysis, there were no significant differences in blood loss, complication, and hospital stay between RAS and LPS surgeries in the treatment of patients with endometriosis. However, RAS surgery required a higher weighted mean operating time than LPS surgery, 0.54 (95% confidence interval; 0.37 to 0.70; p < 0.00001) min. This meta-analysis confirmed that the robotic surgery is safe and feasible in patients affected by endometriosis. We could suggest that RAS is a valid option and might be considered an alternative to LPS especially in advanced cases.

Step by Step Total Laparoscopic Hysterectomy with Uterine Arteries Ligation at the Origin.

STUDY OBJECTIVE: To reveal principles and the feasibility of a total laparoscopic hysterectomy (TLH) with uterine artery ligation at the origin. DESIGN: Step-by-step demonstration and explanation of technique using videos from patients. SETTING: Gynecologic oncology unit at a university hospital. PATIENT: A 54-year-old woman with uterine fibromatosis and metrorrhagia. INTERVENTION: TLH has 7 common components. First, round ligaments are coagulated and cut to enter the retroperitoneum. The ureter is identified. Second, pararectal spaces are entered between the ureter and the internal iliac artery. This maneuver allows the identification of the uterine artery as it leaves its origin from the internal iliac artery. The uterine vessels are stapled with a vascular endoscopic stapler at their origin from the hypogastric vessels or sealed with a bipolar device. Third, adnexal structures are separated from the uterine corpus for subsequent preservation or removal. Fourth, the blood supply is dissected, occluded, and divided before extirpation of the uterine corpus. Fifth, the cardinal ligament complex is transected with colpotomy, and the cervix is amputated from the vaginal apex. Sixth, the specimen is removed. Finally, the vaginal cuff is closed [1]. MEASUREMENTS AND MAIN RESULTS: Laparoscopic hysterectomy was first described by Reich et al. [2] in 1989 and has slowly gained popularity. Today, hysterectomy is the most common gynecologic procedure performed. TLH is where the entire operation (including suturing of the vaginal vault) is performed laparoscopically and there is no vaginal component except for the removal of the uterus. Currently, hysterectomies are performed by different approaches, and individual surgeons have different indications for the approach to hysterectomy based largely on their own array and patient characteristics. TLH requires the highest degree of laparoscopic surgical skills [3], and knowledge of pelvic anatomy defines a safe space for sharp entry into the retroperitoneum and safe identification of pelvic vasculature. CONCLUSION: We present an educational video with step-by-step explanation of the technique to highlight the anatomic landmarks that guides the procedure.

Laparoscopic Approach for Shull Repair of Pelvic Floor Defects.

STUDY OBJECTIVE: To prove the feasibility of the Shull technique by a laparoscopic approach in a patient affected by pelvic organ prolapse (POP) with apical loss of support. DESIGN: A step-by-step video demonstration (Canadian Task Force classification III). SETTING: University hospital. Ethics Committee ruled that approval was not required for this study. PATIENT: A 53-year-old woman with a POP-Q stage IV, left ovarian cyst. INTERVENTION: Laparoscopic uterosacral ligament suspension. MEASUREMENTS AND MAIN RESULTS: According to the National Health and Nutrition Examination Survey, approximately 3% of women in the United States report symptoms linked to POP, with approximately 300 000 POP surgeries each year in the United States. More recent studies show a lower reoperation rate of approximately 6% to 30%, and this lower reoperation rate may reflect improvement in surgical technique and POP surgery that includes suspension of the vaginal apex, which is associated with a decreased reoperation rate, commonly done by vaginal vault suspension to uterosacral ligaments. Suturing the apex to the high (proximal) portion of each uterosacral ligament is more commonly performed vaginally, although abdominal and laparoscopic approaches are suitable. It represents a modification of the uterosacral ligament suspension procedure described by Shull. A 53-year-old woman with a POP-Q stage IV, left ovarian cyst and an "elongatio colli" underwent a total hysterectomy and bilateral ovariectomy with vaginal dome uterosacral ligament suspension performed laparoscopically. The total operating time was 80 minutes, with a blood loss volume of less than 50 mL. The patient was hospitalized for 2 days. There were no postoperative complications in 30 days. CONCLUSION: The Shull laparoscopic surgery for advance POP with reconstruction of the anterior compartment is technically feasible.

Role of blue dye for sentinel lymph node detection in early endometrial cancer.

BACKGROUND: Sentinel Lymphonode analysis has become a barely new and innovative way to treat early stages of endometrial cancer (Ballester et al., Lancet Oncol 469-476, 2011; Buda et al., Ann Surg Oncol 2975-81, 2016). Indocyanine green cervical injection is considered gold standard for mapping nodes' drainage. Blue dye is used as a valid alternative in many centers, due to the lower cost of execution. The objective of this video is to prove that methylene blue dye's cervical injection is a valid and "low-cost" method to obtain mapping of lymphatic drainage in patient with early endometrial cancer. METHODS: Fifty-four-year old women, with a recent diagnosis of endometrial cancer IA G2, we performed a radical Hysterectomy type A. We diluted in equal proportions the blue dye and saline and injected 1 cl in depth and 1 cl on the surface of the cervix, at 3 o'clock and 9 o'clock. After 20 min, it was shown with precision the lymphatic drainage until the first lymph node station from both sides. RESULTS: One external iliac lymph node and one obturator were resected on the left side and one external iliac on the right side. On histological analysis, none of the lymph nodes had any location of metastasis, neither micro-metastasis. Myometrial infiltration was 8/19 mm. CONCLUSIONS: Blue dye cervical injection is a "low-cost", safe, and satisfactory procedure to point out Sentinel Lymph Node of uterus drainage. Other tracers, such as indocyanine green, are widely used in gynecological oncology, but with a higher cost of the product and the needing of a dedicated optical filter to be shown on human view.

Acute dysphagia in an octogenarian: an unusual case of tetanus.

Tetanus is a major worldwide health problem, and its global incidence has been estimated to be approximately 1 million cases per year. In particular, tetanus is more frequent in the elderly as compared with adults. We report a case of an octogenarian who presented with dysphagia and tremors as the only clinical symptoms. During hospitalization, the patient's clinical conditions worsened rapidly, and, although in absence of the classic clinical presentation (trisma, nuchal rigidity, and opisthotonus), a diagnosis of tetanus was suspected. Thus, the patient underwent a tetanus immunoglobulin immunization and antibiotic therapy with excellent clinical recovery.