Laparoscopic Extraperitoneal Approach to Bilateral Pelvic Lymph Node Dissection in Low Rectal Cancer: Technique with Video and 3D Modeling.

BACKGROUND: Lateral pelvic lymph node dissection for rectal cancer is a difficult technique due to the complex pelvic anatomy. Recent series have underlined the importance of lateral lymphadenectomy in selective patients to prevent local recurrence of rectal cancer. METHODS: A 65-year-old woman was diagnosed with locally advanced rectal adenocarcinoma of the low rectum with right and left lateral pelvic lymph nodes of respectively 9 and 13 mm. After chemotherapy followed by radiotherapy, the size of the right internal iliac lymph nodes remained enlarged to 5 mm. A laparoscopic extraperitoneal approach was used for total mesorectal excision, complete mesocolic excision, and bilateral lateral lymph node dissection. The extraperitoneal space was divided into the subperitoneal space dissected by a transanal approach and the retroperitoneal space dissected by a transabdominal approach. RESULTS: The operating time was 303 min, and the estimated blood loss was 270 ml. No intraoperative adverse events occurred. Bilateral lymph node dissection was performed with obturator nerve and neurovascular bundle sparing. A postoperative complication classified as Clavien 3a arose with a pelvic infection but no anastomotic leakage. Final pathology disclosed T3N1M0 adenocarcinoma with free surgical margins. The patient never had urinary dysfunction. CONCLUSIONS: The laparoscopic extraperitoneal approach to lateral pelvic lymph node dissection is feasible. For lateral lymph node dissection, the transanal approach may have some advantages over the standard transabdominal approach, with better visibility of and access to the distal internal iliac area. This video may help oncological surgeons to perform this new and complex procedure.

[Obstetric outcomes after uterine compression suture for treatment of postpartum hemorrhage: Long-term monitoring of 40 cases]. / Devenir obstétrical après plicatures utérines dans le traitement de l'hémorragie de la délivrance : suivi à long terme de 40 cas.

OBJECTIVE: Uterine atony is the first cause of postpartum hemorrhage. In caesarean section, different techniques of uterine compression suture exist when uterotonic drugs fail. Their effectiveness is shown but little data on their effects on subsequent pregnancies are available. The aim of this work is analyze of the obstetrical long-term consequences after uterine compression suture. PATIENTS AND METHODS: This is a retrospective study of 40 cases of uterine compression suture performed in a level III maternity, between 2004 and 2010. The main objective is the evaluation of the obstetrical prognosis of subsequent pregnancies. The efficacy and safety of surgical techniques, according to their transfixing character or not, were analyzed. RESULTS: Eleven pregnancies after uterine compression suture were reported among 14 women whishing another pregnancy. The median time to be pregnant was 27 months (6-78 months). Nine pregnancies were conducted at term. One case of intrauterine growth restriction and a moderate prematurity at 32 weeks were observed. There was no significant difference in efficacy and early surgical complications according to the surgical technique; however, both infectious and ischemic complications were observed after transfixing compression suture. CONCLUSION: The obstetric prognosis after a uterine compression suture is kept. The transfixing techniques may cause more infectious and ischemic complications. An evaluation of surgical techniques depending on their transfixing, or not, character on a large cohort is necessary for the evaluation of the influence of the technique on fertility and postoperative complications.