Society of Robotic Surgery review: recommendations regarding the risk of COVID-19 transmission during minimally invasive surgery.

OBJECTIVES: To determine the risk of COVID-19 transmission during minimally invasive surgical (MIS) procedures METHODS: Surgical society statements regarding the risk of COVID transmission during MIS procedures were reviewed. In addition, the available literature on COVID-19 and other viral transmission in CO2 pneumoperitoneum, as well as the presence of virus in the plume created by electrocautery during MIS was reviewed. The society recommendations were compared to the available literature on the topic to create our review and recommendations to mitigate COVID-19 transmission. RESULTS: The recommendations promulgated by various surgical societies evolved over time as more information became available on COVID-19 transmission. Review of the available literature on the presence of COVID-19 in CO2 pneumoperitoneum was inconclusive. There is no clear evidence of the presence of COVID-19 in plume created by electrocautery. Technologies to reduce CO2 pneumoperitoneum release into the operating room as well as filter viral particles are available and should reduce the exposure risk to operating room personnel. CONCLUSION: There is no clear evidence of COVID-19 virus in the CO2 used during MIS procedures or in the plume created by electrocautery. Until the presence or absence of COVID-19 viral particles has been clearly established, measures to mitigate CO2 and surgical cautery plume release into the operating room should be performed. Further study on the presence of COVID-19 in MIS pneumoperitoneum and cautery plume is needed.

A prospective study of quality of life in patients undergoing pelvic exenteration: interim results.

OBJECTIVE: Little prospective data exist on quality of life (QOL) after pelvic exenteration (PE). This ongoing study prospectively examines the QOL changes following this radical procedure using a comprehensive battery of psychological instruments. METHODS: Since 2005, enrolled patients were interviewed (EORTC QLQ-C30, EORTC QLQ-CR38, EORTC QLQ-BLM30, BFI, BPI-SF, IADL, CES-D, IES-R) preoperatively and at 3, 6, and 12 months after PE for physical/psychological symptoms. Data were examined using repeated measure ANOVA. RESULTS: Sixteen women (3 anterior, 1 posterior, and 12 total PEs), with more than 1 year of follow-up, completed all scheduled interviews. Median age was 58 years (range, 28-76 years). Overall QOL (F = 6.3, p < 0.02), ability to perform instrumental daily activities (F = 6.8, p < 0.02), body image (F = 11.9, p < 0.00), and sexual function (F = 8.0, p < 0.01) all declined at 3 months but were near baseline by 12 months after PE. Although, overall, physical function followed a similar trend (F = 14.8, p < 0.00), it did not return to baseline. At the 12-month interview, patients reported increased gastrointestinal symptoms (F = 8.9, p < 0.01) but significantly less stress-related ideation (F = 6.1, p < 0.03) compared to baseline. Pain levels did not change significantly during the study period (F = 0.4, p < 0.74). CONCLUSIONS: Although patients report lingering gastrointestinal symptoms and some persistent decline in physical function after PE, most adjust well, returning to almost baseline functioning within a year. Providers can counsel patients that many, though not all, symptoms in the first 3 months following exenteration are likely to improve as they adapt to their changed health status. These preliminary results await confirmation of a larger analysis.

A randomized, single-blinded pilot study evaluating use of a laparoscope or a cystoscope for cystoscopy during gynecologic surgery.

STUDY OBJECTIVE: To prospectively evaluate time required to perform cystoscopy with a laparoscope or a cystoscope after laparoscopic hysterectomy. Urinary tract symptoms, infection, adverse events, and expense were also evaluated. DESIGN: Randomized, single-blind pilot study (Canadian Task Force classification I). SETTING: Suburban private gynecology group practice and local community hospital. SUBJECTS: Sixty-six subjects scheduled to undergo laparoscopic hysterectomy between January and July 2009. INTERVENTION: Either cystoscopy with a laparoscope or a cystoscope. MEASUREMENTS AND MAIN RESULTS: Subjects were randomized to undergo either form of cystoscopy, and events were reported. Each subject completed self-reported urinary tract symptom questionnaires before surgery and at 2 weeks after surgery. Clean-catch urine samples were obtained before surgery and postoperatively at day 1 and 2 weeks. In the group who underwent laparoscope cystoscopy, a suction-irrigator device, a 5-mm needle-nose suction irrigator tip, and a 5-mm 0-degree video laparoscope were required. In the group who underwent traditional cystoscopy, a 70-degree video telescope with a 17F sleeve, irrigation fluid, and a light source were required. Subjects were followed up for 6 weeks postoperatively. Adverse events were minimal, with 1 in the laparoscope group and 6 in the traditional cystoscope group. Two postoperative urinary tract infections occurred in the traditional cystoscopy group. The mean total procedural time for laparoscope cystoscopy of 137 seconds was statistically less (p < .001) compared with the 296 seconds in the traditional cystoscopy group. Improvements in urinary tract symptom scores improved from baseline, but were not statistically significantly different between the groups. Traditional cystoscopy equipment cost approximately $60 more per subject. CONCLUSION: The study results suggest that laparoscope cystoscopy is more time-efficient and cost-effective than traditional cystoscopy and that the incidence of urinary tract symptoms, infection, and injury did not increase.

Diagnostic laparoscopy and adhesiolysis: does it help with complex abdominal and pelvic pain syndrome (CAPPS) in general surgery?

Abdominal pains secondary to adhesions are a common complaint, but most surgeons do not perform surgery for this complaint unless the patient suffers from a bowel obstruction. The purpose of this evaluation was to determine if lysis of bowel adhesions has a role in the surgical management of adhesions for helping treat abdominal pain. The database of our patients with complex abdominal and pelvic pain syndrome (CAPPS) was reviewed to identify patients who underwent a laparoscopic lysis of adhesion without any organ removal and observe if they had a decrease in the amount of abdominal pain after this procedure. Thirty-one patients completed follow-up at 3, 6, 9, and 12 months. At 6, 9, and 12 months postoperation, there were statistically significant decreases in patients' analog pain scores. We concluded that laparoscopic lysis of adhesions can help decrease adhesion-related pain. The pain from adhesions may involve a more complex pathway toward pain resolution than a simple cutting of scar tissue, such as "phantom pain" following amputation, which takes time to resolve after this type of surgery.

Robotic single-site endometriosis resection using near-infrared fluorescence imaging with indocyanine green: a prospective case series and review of literature.

We present our preliminary experience comparing robotic near-infrared fluorescence (NIRF) imaging using indocyanine green (ICG) to 2D laparoscopic white light (WL) and 3D robotic WL illumination, in their ability to visually detect endometriosis lesions during a robotic endometriosis resection procedure in a single center. A total of twenty women were screened and seven of them with symptomatic endometriosis were included in this prospective case series. The mean patient age was 33 years with the mean body mass index being 28.6 kg/m2. The NIRF-ICG imaging technique enabled visualization of a statistically significant higher number of lesions compared to that of robotic and laparoscopic WL (13.4 vs 7.4 vs 4.7, p = 0.012). In addition, we explored the extent of quality of life (QoL) measures of these women affected by endometriosis using the validated QoL RAND Short Form Health Survey questionnaire and Numeric Pain Rating Scale. The largest reduction of quality of life was measured for the domains of social functioning (3.28 SD, 95% CI 45.7-61.5, p = 0.0001), physical limitations (3.04 SD, 95% CI 15.1-44.3, p = 0.0002), and physical functioning (3.02 SD, 95% CI 48.7-64.1, p = 0.0002), respectively. There was a significant reduction in the postoperative mean pain score as indicated by the pain rating of 0.57 ± 0.78 (p = 0.0005). We also performed a literature search to review other cases that describe the potential benefits of robotic NIRF-ICG imaging in the visual detection of peritoneal and deep endometriosis. Our study results demonstrate that the ICG fluorescence system may potentially be useful for more complete intraoperative endometriosis lesion detection and excision. Large multicenter trials with larger sample sizes and across surgeons of differing experience levels are needed to investigate the clinical utility, reproducibility and long-term outcomes of the use of this technology for patients with debilitating endometriosis.

Fallopian tube prolapse after total laparoscopic hysterectomy.

BACKGROUND: Fallopian tube prolapse is an uncommon but reported complication after laparoscopic hysterectomy. CASE: Fallopian tube prolapse was diagnosed in a patient 6 months after undergoing a total laparoscopic hysterectomy. The presenting symptoms were midline abdominal pain, abdominal distention, and dyspareunia. A laparoscopic approach showed a portion of fallopian tube prolapsed through the vaginal cuff. CONCLUSION: This case suggests that fallopian tube prolapse can occur up to 6 months after a total laparoscopic hysterectomy. Once detected, fallopian tube prolapse can be managed using a laparoscopic approach in select patients.

Colorectal stents for palliation of large-bowel obstructions in recurrent gynecologic cancer: an updated series.

OBJECTIVE: Malignant large-bowel obstruction in the acute setting is considered a surgical emergency. Surgical intervention has been the standard treatment for patients presenting with large-bowel obstruction. Surgery in severely ill patients, however, can be associated with significant morbidity and mortality. Our objective was to review and update our experience with colonic stent placement for patients presenting with a large-bowel obstruction due to recurrent gynecologic malignancy. METHODS: We reviewed the records of all patients with gynecologic cancer who underwent colorectal stent placement for palliation of a large-bowel obstruction from January 2001 to October 2006. RESULTS: Thirty-five patients were identified--25 patients had recurrent ovarian cancer, 7 patients had recurrent endometrial cancer, 2 patients had primary peritoneal carcinoma, and 1 patient had recurrent cervical cancer. The median age at the time of stent placement was 54 years (range, 21-79). The median length of the large-bowel obstruction was 6.5 cm (range, 1-20 cm). Six patients had a lumen of 1 to 2 mm before stent placement, while 29 patients had complete obstruction and needed balloon dilatation before deployment of the stent. Twenty-seven patients (77%) underwent successful stent placement and immediate decompression at the time of colorectal stent placement. Of the patients who had successful stent placement, 9 (33%) underwent additional surgery to relieve obstruction-drainage gastrotomy, 3; colostomy, 4; and stent revision, 2. Eight patients (23%) had failed stent placement secondary to non-traversable strictures and angulation of the bowel. Of these 8 patients, 5 needed colostomy and 3 needed gastrotomy. Of the 27 patients who underwent successful stent placement, the median survival after placement was 7.7 months (95% CI, 3.19-11.9 months). CONCLUSION: In the management of patients with large-bowel obstructions due to recurrent gynecologic cancer, colonic stents appear to be a reasonable option that may enable patients to avoid major surgery.

Vaginal Cuff Closure in Minimally Invasive Hysterectomy: A Review of Training, Techniques, and Materials.

Hysterectomy is one of the most common surgeries performed each year and can be indicated for many gynecologic conditions. The development of minimally invasive surgery has transformed this procedure, resulting in improved outcomes, superior cosmesis, and quicker return to normal function. Vaginal cuff closure is a critical component of hysterectomy, with many variations in surgical technique and materials. This review provides an overview of intracorporeal suturing and knot-tying techniques at the level of a junior resident in obstetrics and gynecology and describes several validated models that have been developed to test resident skill level in vaginal cuff closure. We also provide a review of the literature regarding vaginal cuff closure techniques and suture materials, including knotless barbed sutures. Finally, a brief discussion of single-site surgery, the latest development in minimally invasive hysterectomy, will be provided. We hope to provide a better understanding of vaginal cuff closure for residents in the field of obstetrics and gynecology.

Identification of prognostic factors after positive second-look surgery in epithelial ovarian carcinoma.

OBJECTIVE: The objective of this study was to identify independent prognostic factors for survival in patients with epithelial ovarian cancer who had persistent disease identified at second-look surgery. METHODS: We performed a retrospective chart review of all patients with epithelial ovarian cancer who had positive findings at second-look surgery between June 1991 and June 2002. All patients achieved a complete clinical remission after a prescribed course of primary therapy. Survival was determined from the time of second-look surgery until last follow-up or death. RESULTS: The study included a total of 262 patients, with a median age of 54 years (range, 22-80). Of the 262 patients, 166 (63%) had died of disease. Records of initial (salvage) treatment after the positive second-look surgery were available for 243 patients. Therapies included the following: intraperitoneal (IP) cisplatin, 71 (29%); IP cisplatin combined with a second drug, 53 (22%); IP therapy other than cisplatin, 29 (12%); intravenous (IV) chemotherapy, 50 (21%); IP and IV therapy, 35 (14%); and oral chemotherapy, 5 (2%). Of the 13 potential prognostic factors analyzed, only 2 factors emerged that, when combined, were significant--residual disease after primary surgery and size of persistent disease found at second-look surgery. Patients with