Feasibility and perioperative outcomes of robotic-assisted surgery in the management of recurrent ovarian cancer: A multi-institutional study

Objectives

Minimally invasive surgery for recurrent ovarian cancer is generally not performed. The aim of this study was to assess the feasibility and surgical outcomes of robotic-assisted surgery in the management of recurrent ovarian cancer.

Methods

Eligible patients included those with confirmed recurrent ovarian cancer amenable to surgical resection and in which a complete resection was thought to be feasible with the use of the robotic platform. Patients with evidence of carcinomatosis were not considered for a robotic approach. Clinical and pathologic data were abstracted from the medical records. Appropriate statistical tests were performed using SPSS statistical software program (SPSS 20.0 Inc., Chicago, IL).

Results

A total of 48 patients were identified. Thirty-six (75%) patients had a recurrent mass or masses isolated to one anatomic region (pelvis or abdomen). Conversion to laparotomy was necessary in 4 (8.3%) cases. In cases not requiring conversion to laparotomy, the median operative time, EBL, and length of stay were 179.5 min, 50 cc, and 1 day, respectively. An optimal debulking was achieved in 36 (82%) cases. Complications occurred in 6 (13.6%) cases. The median operative time, EBL, length of stay, and complications were all statistically significantly lower in the cases not converted to laparotomy compared to those that were (p < 0.001).

Conclusions

This study suggests that select patients with recurrent ovarian cancer in the absence of carcinomatosis may be candidates for secondary surgical cytoreduction via a robotic approach. Surgical and postoperative outcomes appear to be favorable compared to reports of laparotomy in recurrent ovarian cancer.     

Cirugía ginecológica en la paciente obesa

Surgery in the obese patient is a challenge for the surgeon and anaesthetist as it is associated with an increase in intra- and post-operative complications. Adverse effects, such as surgical site infection, thromboembolic disease, or surgical wound complications are more frequent in these patients. Minimally invasive surgery has led to an advance in the surgical treatment of these patients, reducing some complications associated with the laparotomy approach, especially in the management of gynaecological cancer. The development of robotic surgery has led to an improvement in the limitations of laparoscopic surgery, due to greater accuracy or 3D vision. Specifically, in the obese patient, robotic surgery provides advantages, such as reduction of intra- and post-operative complications, greater number of lymph nodes, a reduction in hospital stay, as well as less surgical bleeding compared to other approaches.     

Robotic,Laparoscopic, or Open Hysterectomy: Surgical Outcomes by Approach in Endometrial Cancer

Study Objectives

To compare patient outcomes by surgical approach in the management of endometrial cancer (EC) in Washington State from 2008 to 2013.

Perisurgical smoking cessation and reduction of postoperative complications

OBJECTIVE: The purpose of this study was to determine if a perisurgical smoking cessation program reduces smoking-related postoperative complications in urogynecologic surgery. STUDY DESIGN: A review of patients that underwent pelvic reconstructive surgery from 1998 to 2003 was performed. All smokers underwent a perisurgical smoking cessation program of their choice for at least 1 month before surgery, and continued for 1 month after surgery. Complications unrelated to smoking (cystotomy, enterotomy, urethral obstruction, etc) were excluded in the smoking-potentiated complications. Problems considered to be potentiated by smoking were: wound, pulmonary, cardiac, and febrile morbidity. RESULTS: Eight hundred eighty-seven patients were included. There were 233 smoker cessation patients (SC) and 654 nonsmokers (NS). The total number of complications in the SC group was 61 (61/233, 26%) compared with 172 (172/654, 29%) in the NS group: (chi-square, P = .97). When looking at smoking-potentiated complications only, there were 34 (34/61, 56%) patients in the SC group and 90 (90/172, 52%) in the NS group (chi-square, P = .75). CONCLUSION: There are no differences in smoking-potentiated complications between nonsmoking patients and patients who undergo a perisurgical smoking cessation program.     

Robotic Assistance Confers Ambidexterity to Laparoscopic Surgeons

Study Objective

To examine whether a robotic surgical platform can complement the fine motor skills of the nondominant hand, compensating for the innate difference in dexterity between surgeon's hands, thereby conferring virtual ambidexterity.

Hymen Sparing Surgery for Imperforate Hymen: Case Reports and Review of Literature

BackgroundImperforate hymen, with an incidence between 0.1% and 0.05%, is the most common obstructive congenital abnormality of the female genital tract. 'Standard' surgical treatment of imperforate hymen involves hymenectomy after a cruciate, plus, or X-shaped hymenotomy incision.CasesTwo cases with imperforate hymen treated with a simple vertical incision are presented. A few oblique sutures were used to prevent refusion. Postoperative follow up was uneventful.Summary and ConclusionThe importance of the integrity of hymen changes in different cultures and religious groups. Option of a hymen sparing procedure is readily preferred by most of these patients and families. Also preservation of hymenal tissue, hence the perception of 'integrity' of female genitalia, might be an alternative treatment option.     

Tissue integration and tolerance to meshes used in gynecologic surgery: an experimental study

OBJECTIVE: To evaluate the tissue integration of and tolerance to five different mesh types used in genital prolapse surgery to provide mechanical support. STUDY DESIGN: We placed five different meshes (Vicryl, Vypro, Prolene, Prolene soft, and Mersuture) on the peritoneums of 12 pigs. After 10 weeks, we used light microscopy to analyze the tissue integration of and tolerance to these meshes. We looked for inflammation, vascularization, fibroblasts, collagen fibers and the organization of connective tissue. RESULTS: The absorbable prostheses made of polyglactin 910 (Vicryl) and the non-absorbable prostheses made of polypropylene (Prolene and Prolene soft) induced the least severe inflammatory reactions. Tissue integration was best with the polypropylene meshes, which allowed the development of a well-organized, fibrous, mature, connective tissue. CONCLUSION: The tissue response to prosthetic meshes depends on the material used and its structure. This work highlights the feasibility of carrying out experimental studies to test the tolerance to and integration of biomaterials used in gynecology. Such studies need to be carried out whenever new prostheses become available to validate their use in common practice.     

Evaluation of the American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator in Gynecologic Oncology Patients Undergoing Minimally Invasive Surgery

Study Objective

To evaluate the ability of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) surgical risk calculator to predict discharge to postacute care and perioperative complications in gynecologic oncology patients undergoing minimally invasive surgery (MIS).

A phase II trial of a surgical protocol to decrease the incidence of wound complications in obese gynecologic oncology patients

Objectives

Obese women have a high incidence of wound separation after gynecologic surgery. We explored the effect of a prospective care pathway on the incidence of wound complications.

Methods

Women with a body mass index (BMI) ≥ 30 kg/m² undergoing a gynecologic procedure by a gynecologic oncologist via a vertical abdominal incision were eligible. The surgical protocol required: skin and subcutaneous tissues to be incised using a scalpel or cutting electrocautery, fascial closure using #1 polydioxanone suture, placement of a 7 mm Jackson-Pratt drain below Camper's fascia, closure of Camper's fascia with 3-0 plain catgut suture and skin closure with staples.Wound complication was defined as the presence of either a wound infection or any separation. Demographic and perioperative data were analyzed using contingency tables. Univariable and multivariable regression models were used to identify predictors of wound complications. Patients were compared using a multivariable model to a historical group of obese patients to assess the efficacy of the care pathway.

Results

105 women were enrolled with a median BMI of 38.1. Overall, 39 (37%) had a wound complication. Women with a BMI of 30–39.9 kg/m² had a significantly lower risk of wound complication as compared to those with a BMI > 40 kg/m² (23% vs 59%, p < 0.001). After controlling for factors associated with wound complications the prospective care pathway was associated with a significantly decreased wound complication rate in women with BMI < 40 kg/m² (OR 0.40, 95% C.I.: 0.18–0.89).

Conclusion

This surgical protocol leads to a decreased rate of wound complications among women with a BMI of 30–39.9 kg/m².     

Papel de la histerectomía en el sangrado uterino anormal

Abnormal uterine bleeding is a frequent reason for consultation in the field of gynaecology of great physical, emotional, and social impact. There are several current treatment options, and management depends on the clinical scenario.The definitive treatment of abnormal uterine bleeding involves performing a hysterectomy which is not risk free. An exhaustive evaluation of the comorbidities and, whenever feasible, minimally invasive surgery should be performed.In developing countries, surgery remains the first choice for abnormal uterine bleeding treatment due to the lack of resources to access the new medical therapies available. Access to minimally invasive surgical techniques is also more restricted. For this reason, the big challenge is to ensure equal access to resources and improvements around the world.     

Vulvar Metastasis of an Early-Stage Well-Differentiated Endometrial Cancer After Minimally Invasive Surgery

Endometrial cancer is the most common gynecologic malignancy, often manifesting as early-stage well-differentiated endometrioid adenocarcinoma associated with a high likelihood of long-term recurrence-free survival. Minimally invasive surgery for surgical staging of endometrial lesions is now routinely practiced, with laparoscopy the preferred surgical approach at many cancer centers. Recurrence or metastasis of early-stage well-differentiated endometrial endometrioid adenocarcinoma is uncommon, and may occur due to iatrogenic microscopic seeding of malignant cells during surgery, as suggested by previous reports of cancer metastasis to port sites after minimally invasive surgery, laparotomy incisions after open surgery, or intraperitoneal spread after hysteroscopy or uterine manipulation. Herein we report the only described case of isolated vulvar metastasis of an early-stage FIGO stage IB well-differentiated (histologic grade 1) endometrial endometrioid adenocarcinoma after minimally invasive surgery for surgical staging. The patient had recurrent endometrioid adenocarcinoma metastasis at the vulva 8 months after robotic-assisted total laparoscopic hysterectomy and surgical staging with specimen removal through the vagina. In selected cases, we suggest that use of a specimen bag during removal of the uterus through the vagina may limit seeding of malignant cells during minimally invasive surgery to treat cancer.     

Sacrocolpopexy for Treatment of Vaginal Apical Prolapse: Evidence-Based Surgery

Pelvic organ prolapse is a common condition that negatively affects womens' quality of life. Sacrocolpopexy is an abdominal procedure designed to treat apical compartment prolapse including uterine or vaginal vault prolapse and multiple-compartment prolapse. Although traditionally performed as an open abdominal procedure, minimally invasive sacrocolpopexy, whether laparoscopic or robotic, has been successfully adopted in the practice of many pelvic reconstructive surgeons. There are many variations to this procedure, with different levels of evidence to support each of them. Herein we review the current literature on sacrocolpopexy, with emphasis on the minimally invasive approach. Procedural steps and controversies are examined in light of the existing literature, and recommendations are made on the basis of the level of existing evidence.     

The surgical rectus sheath block for post-operative analgesia: a modern approach to an established technique

Objective

To describe the surgical rectus sheath block for post-operative pain relief following major gynaecological surgery.

Technique

Local anaesthetic (20 ml 0.25% bupivacaine bilaterally) is administered under direct vision to the rectus sheath space at the time of closure of the anterior abdominal wall.

Study design

We conducted a retrospective case note review of 98 consecutive patients undergoing major gynaecological surgery for benign or malignant disease who received either standard subcutaneous infiltration of the wound with local anaesthetic (LA, n = 51) or the surgical rectus sheath block (n = 47) for post-operative pain relief.

Main outcome measures

(1) Pain scores on waking, (2) duration of morphine-based patient controlled analgesia (PCA), (3) quantity of morphine used during the first 48 post-operative hours and (4) length of post-operative stay.

Results

The groups were similar in age, the range of procedures performed and the type of pathology observed. Patients who received the surgical rectus sheath block had lower pain scores on waking [0 (0-1) vs. 2 (1-3), p < 0.001], required less morphine post-operatively [12 mg (9-26) vs. 36 mg (30-48), p < 0.001], had their PCAs discontinued earlier [24 h (18-34) vs. 37 h (28-48), p < 0.001] and went home earlier [4 days (3-4) vs. 5 days post-op (4-8), p < 0.001] [median (interquartile range)] than patients receiving standard subcutaneous local anaesthetic into the wound.

Conclusions

The surgical rectus sheath block appears to provide effective post-operative analgesia for patients undergoing major gynaecological surgery. A randomised controlled clinical trial is required to assess its efficacy further.     

Cirugía laparoscópica en tiempos de COVID-19

Coexistence with COVID-19 infection (coronavirus disease 2019) in all hospital and health care settings is a current challenge of adaptation, as well as the creation of new protocols and care models. At present, there are still many unknowns about this infection, and much more unknown is the impact into the surgical field. Although evidence regarding the effect of SARS-CoV-2 and laparoscopic surgery is scarce, laparoscopy has been considered the method of choice by different scientific societies for most indications in gynaecology during the COVID-19 pandemic. This is due to the advantages over the open route. There is less morbidity and hospital stay, and in addition, as it involves autonomous and contained surgical procedures with respect to smoke release. Moreover, the instruments and the setting in the operating room mean that there can be safe distance from the surgeon and other staff to the patient. Overall, the main recommendations in laparoscopic surgery during the COVID era include: the use of Personal Protective Equipment for operating room personnel, and the adoption of safety measures to reduce CO₂ exposure and surgical smoke release.     

NEST (network enhanced surgical training): A PC-based system for telementoring in gynaecological surgery

Objectives

To develop and describe NEST (network enhanced surgical training), an affordable and easily reproducible telementoring system.

Study design

We have developed the system around two standard personal computers: a desktop computer for the surgeon in the operating room (OR), equipped with a digital video-capture system; and a laptop computer for a mentor outside the OR. In an attempt to reduce the costs, freeware software has been tested and chosen to allow visual and audio interaction between the two computers. No IT technicians were involved in the process at any stage.

Results

Following 6 months of hardware and software testing, we have successfully developed NEST (network enhanced surgical training), an affordable telementoring system based on two standard personal computers connected through an Ethernet cable. We tried NEST during the whole range of gynaecologic interventions performed in our unit, including abdominal, vaginal and laparoscopic surgery. We also successfully used NEST to provide visual access to the operative field to medical students and endoscopy workshop delegates. In addition, we also used NEST to simulate telementoring during pelvi-trainer sessions in our endoscopy skills laboratory. Surgeons’ interaction through NEST seems reliable since the mentor's instructions, both vocal and visual (by pointing at landmarks), were always followed on time by the surgeon during our tests.

Conclusions

We believe that surgical telementoring deserves attention and our NEST system could be an ideal tool for studies on telementoring in safe environments. In its simplest incarnation with the mentor “next-door”, just outside the operating theatre, he/she could intervene at any stage if necessary. Moreover, NEST is affordable and reproducible as it is based solely on two standard personal computers, a video-capture system, an Ethernet cable, and two freeware computer programs.