Dermoid tumors of the ovary: evaluation of the gasless lift-laparoscopic approach.

Laparoscopic removal is widely accepted as the treatment of choice for dermoid tumors. However, the spillage of dermoid content with the laparoscopic approach is very high compared to laparotomy. The potential malignancy of dermoid tumors and the rare, but difficult to treat, chemical peritonitis in cases of spillage of dermoid content should lead to an adaptation of procedures during an endoscopic operation on a dermoid tumor to comply with the precautions of the "open" technique. Lift-laparoscopy combines laparoscopy with the standard procedures of laparotomy and thus may help reduce the spillage of dermoid contents. In a retrospective study of 108 patients with dermoid tumors, the frequency of the rupture of a dermoid tumor during a lift-laparoscopic operation was examined. Among the 79 cases of organ-preserving treatment, there were only three cases (3.8%) where a rupture of the dermoid capsule occurred. Even in cases of ruptures, it was possible to avoid spillage by closing the lesion with a clamp and continue the enucleation of the dermoid tumor during a lift-laparascopic operation. After thorough abdominal cavity lavage, none of these three cases showed a cytological contamination of the abdominal cavity with dermoid cells. None of the ovariectomy or adnexectomy cases showed a rupture. Histologically, there was also no carcinoma in any of the examined dermoid tumors. By adapting the endoscopic dermoid surgery to the precautions established in an open surgery technique using gasless lift-laparoscopy, ruptures and cell spilling can be avoided to a large extent but not completely excluded. Compared with other methods, the number of ruptures and spillage of dermoids by organ-preserving treatment as well as ovariectomy is lowest using a lift-laparoscopic procedure.

Adhesiolysis in severe and reccurent cases of adhesions related disorder (ARD) - a novel approach utilizing lift (gasless) laparoscopy and SprayGel adhesion barrier.

We investigated the feasibility and outcome of adhesiolysis in patients with severe and reccurent adhesions using lift (gasless) laparoscopy and a SprayGel adhesion barrier at the Institute for Endoscopic Gynecology (EndoGyn). The design included a prospective evaluation of lift (gasless) laparoscopic adhesiolysis in combination with a SprayGel adhesion barrier. A new score for bowel adhesions was developed and applied. All 35 patients with severe and reccurent adhesions underwent a lift-laparoscopic adhesiolysis with the Abdo-Lift and SprayGel adhesion barrier, a second-look laparoscopy at Day 7 and, in case of continuation of pain, a third-look laparoscopy within 6 months after the initial surgery. All patients were operated upon without conversion to laparotomy. The reduction in the adhesion score of adhesions at the second-look laparoscopy was overall (sum) 89.8% (90.1% reduction in extent, 89.3% reduction in severity, and 89.9% reduction in grade). Five patients (14.3%) had a third-look laparoscopy within 6 months after the initial surgery, in which four cases of adhesion reformation were confirmed. However, the scores were reduced compared to the initial surgery, especially in grade (94.2%) and severity (93.2%). In these analyses, SprayGel was uniquely effective in improving the success rates of adhesiolysis when combined with lift (gasless) laparoscopy and good hemostasis techniques. Adhesiolysis with Abdo-Lift and SprayGel had unparalleled efficacy in the adhesiolysis procedure even in those patients in whom other solutions have not worked. An overall reduction of adhesions by 89.9% at second-look laparoscopy was found. Even if five patients (14.3%) required a third-look laparoscopy where four cases of adhesion reformation were confirmed, the scores were reduced when compared to the initial surgery, especially in grade and severity.

Lift-(gasless) laparoscopic surgery under regional anesthesia.

The objective of this Chapter was to investigate the feasibility and outcome of gasless laparoscopy under regional anesthesia. A prospective evaluation of Lift-(gasless) laparoscopic procedures under regional anesthesia (Canadian Task Force classification II-1) was done at three endoscopic gynecology centers (franchise system of EndGyn(r)). Sixty-three patients with gynecological diseases comprised the cohort. All patients underwent Lift-laparoscopic surgery under regional anesthesia: 10 patients for diagnostic purposes, 17 for surgery of ovarian tumors, 14 to remove fibroids, and 22 for hysterectomies. All patients were operated without conversion to general anesthesia and without perioperative or anesthesiologic complications. Lift-laparoscopy under regional anesthesia can be recommended to all patients who desire laparoscopic intervention without general anesthesia. For elderly patients, those with cardiopulmonary risks, during pregnancy, or with contraindications for general anesthesia, Lift-laparoscopy under regional anesthesia should be the procedure of choice.

Lift-laparoscopic total hysterectomy as a routine procedure.

In this study, laparoscopic hysterectomy was done with a special lift system that elevates the abdominal wall without carbon dioxide (CO2) insufflation. During this procedure, bipolar diathermy scissors also were used, which disconnected the uterus from its vessels and ligaments. The uterus was then removed through the vagina. In 403 cases, variables including operation time, complication rate, blood loss, postoperative pain, hospital stay, vaginal discharge, and convalescence time were examined. Compared with other laparoscopic methods [laparoscopic-assisted vaginal hysterectomy (LAVH), supracervical hysterectomy, and total laparoscopic hysterectomy], all those examined showed better results. Further advantages of the gasless Lift-laparoscopic total hysterectomy are lower costs and an effective "learning curve." Use of this method routinely could decrease the number of conventional-surgical hysterectomies that result in additional complications.

Insights into the catalytic mechanism of human sEH phosphatase by site-directed mutagenesis and LC-MS/MS analysis.

We have recently reported that human soluble epoxide hydrolase (sEH) is a bifunctional enzyme with a novel phosphatase enzymatic activity. Based on a structural relationship with other members of the haloacid dehalogenase superfamily, the sEH N-terminal phosphatase domain revealed four conserved sequence motifs, including the proposed catalytic nucleophile D9, and several other residues potentially implicated in substrate turnover and/or Mg(2+) binding. To enlighten the catalytic mechanism of dephosphorylation, we constructed sEH phosphatase active-site mutants by site-directed mutagenesis. A total of 18 mutants were constructed and recombinantly expressed in Escherichia coli as soluble proteins, purified to homogeneity and subsequently analysed for their kinetic parameters. A replacement of residues D9, K160, D184 or N189 resulted in a complete loss of phosphatase activity, consistent with an essential function for catalysis. In contrast, a substitution of D11, T123, N124 and D185 leads to sEH mutant proteins with altered kinetic properties. We further provide evidence of the formation of an acylphosphate intermediate on D9 by liquid chromatography-tandem mass spectrometry based on the detection of homoserine after NaBH(4) reduction of the phosphorylated enzyme, which identifies D9 as the catalytic nucleophile. Surprisingly, we could only show such homoserine formation using the D11N mutant, which strongly suggests D11 to be involved in the acylphosphate hydrolysis. In the D11 mutant, the second catalytic step becomes rate limiting, which then allows trapping of the labile intermediate. Substrate turnover in the presence of (18)H(2)O revealed that the nucleophilic attack during the second reaction step occurs at the acylphosphate phosphorous. Based on these findings, we propose a two-step catalytic mechanism of dephosphorylation that involves the phosphate substrate hydrolysis by nucleophilic attack by the catalytic nucleophile D9 followed by hydrolysis of the acylphosphate enzyme intermediate supported by D11.

The N-terminal domain of mammalian soluble epoxide hydrolase is a phosphatase.

The mammalian soluble epoxide hydrolase (sEH) is an enzyme with multiple functions, being implicated in detoxification of xenobiotic epoxides as well as in regulation of physiological processes such as blood pressure. The enzyme is a homodimer, in which each subunit is composed of two domains. The 35-kDa C-terminal domain has an alpha/beta hydrolase fold and harbors the catalytic center for the EH activity. The 25-kDa N-terminal domain has a different alpha/beta fold and belongs to the haloacid dehalogenase superfamily of enzymes. The catalytic properties of the enzyme reported so far can all be explained by the action of the C-terminal domain alone. The function of the N-terminal domain, other than in structural stabilization of the dimer, has therefore remained unclear. By structural comparison of this domain to other haloacid dehalogenase family members, we identified a putative active site containing all necessary components for phosphatase activity. Subsequently, we found rat sEH hydrolyzed 4-nitrophenyl phosphate with a rate constant of 0.8 s(-1) and a K(m) of 0.24 mM. Recombinant human sEH lacking the C-terminal domain also displayed phosphatase activity. Presence of a phosphatase substrate did not affect epoxide turnover nor did epoxides affect dephosphorylation by the intact enzyme, indicating both catalytic sites act independently. The enzyme was unable to hydrolyze 4-nitrophenyl sulfate, suggesting its role in xenobiotic metabolism does not extend beyond phosphates. Thus, we propose this domain participates instead in the regulation of the physiological functions associated with sEH.