Treatment of ovarian dermoid cysts

The purpose of this study was to discuss the place and the specific modalities of laparoscopic surgery in the management of ovarian dermoid cysts. This retrospective and noncomparative study was carried out in 65 patients who presented dermoid ovarian cyst between January 1986 and December 1990 in our institution. The surgical treatment was performed purely by laparoscopy in 86.2% of the cases (56 patients). The modalities of laparoscopic surgery were as follows: ovariectomy (8 cases; 14.3%), transparietal cystectomy (4 cases; 7.1%) and intraperitoneal cystectomy (44 cases; 78.6%). In 15 cases (15/44=34%) the intraperitoneal cystectomy was carried out without opening the cyst and the intact cyst was extracted using an endoscopic impermeable sack. We observed no cases of chemical peritonitis. The risk of recurrence after conservative treatment is 4% (two patients) and out of the ten patients for whom a second-look laparoscopy was performed only two (20%) presented adhesions. Laparoscopic treatment of dermoid ovarian cysts is feasible, safe, and effective. The treatment can be conservative in over 80% of the cases. The specific risk of chemical peritonitis can be countered by a change in the cystectomy technique. The use of an impermeable laparoscopic sack permits extraction of the cyst without any peritoneal contamination.     

Dilation of the vaginal cuff using the Bakri Postpartum Balloon to extract the large uterus at the time of robotic hysterectomy for endometrial carcinoma

Removal of large uterine specimens during robotic or total laparoscopic hysterectomy poses surgical challenges, particularly in cases performed for gynecologic malignancy. A 23-year-old patient with endometrioid adenocarcinoma of the endometrium underwent robotic total laparoscopic hysterectomy with bilateral salpingo-oophorectomy. The large uterine specimen was removed by dilating the colpotomy incision using the Bakri Postpartum Balloon?. Dilation of the colpotomy incision with the uterine tamponade balloon can allow for the intact removal of a large uterine specimen in cases of robotic or total laparoscopic hysterectomy performed for gynecologic malignancy when specimen morcellation is contraindicated.     

Laparoscopic management of chemical peritonitis caused by dermoid cyst spillage

Background:

Dermoid cyst is the most frequent benign ovarian tumor. Spillage of cyst contents during surgery is common and can rarely lead to chemical peritonitis.

Case Report:

A patient presented 3 days after attempted laparoscopic removal of bilateral dermoid cysts. On examination, she had a low-grade fever, rebound tenderness with guarding, and a markedly elevated white blood cell count. A decision was made to proceed with laparoscopy with the presumptive diagnosis of chemical peritonitis. Laparoscopic findings included residual dermoid cyst contents and extensive filmy adhesions of the bowel and omentum to the peritoneal surface. The chemical peritonitis resolved after laparoscopic removal of residual dermoid cyst content including bilateral salpingo-oophorectomy and copious irrigation.

Conclusion:

Early recognition and prompt treatment by repeat laparoscopic surgery with removal of the remaining cyst contents and peritoneal lavage can be a successful method for treating chemical peritonitis.     

单孔腹腔镜在巨大卵巢囊肿剔除术中的应用

目的探讨单孔腹腔镜技术在卵巢巨大囊肿剥除术中的应用价值。 方法回顾性分析2017年3月至2018年3月在北京协和医院妇产科进行单孔腹腔镜辅助下巨大卵巢囊肿体外剥除术的9例患者的临床资料,其中2例为孕13^＋周;根据术后病理类型分类：其中5例为黏液性囊腺瘤,2例为畸胎瘤,1例为子宫内膜异位囊肿,1例为单纯囊肿。 结果9例患者均顺利在单孔腹腔镜辅助下完成巨大卵巢囊肿体外剥除,无患者中转开腹或多孔腹腔镜,围手术期无手术相关并发症发生。中位手术时间55 min(35～60 min),中位术中出血量10 ml(10～75 ml),平均术后住院时间(5.11±1.41)d。其中2例妊娠患者均顺利足月阴道分娩,1例患者术后3个月自然妊娠,6例患者术后6～12个月复查超声均无复发。 结论术前严格筛查排除恶性卵巢肿瘤可能,行单孔腹腔镜辅助下巨大卵巢囊肿体外剥除术为治疗卵巢巨大囊肿提供了一种安全可行的方法。     

腹腔镜治疗卵巢皮样囊肿手术技巧的总结(附108例分析)

目的:总结腹腔镜治疗卵巢皮样囊肿的手术技巧。方法:对108例腹腔镜治疗卵巢皮样囊肿手术处理和取物方法进行分析总结。结果:108例腹腔镜手术治疗卵巢皮样囊肿,其中48例采用直接剥离法,54例行穿刺抽吸法,6例腹腔镜辅助下腹部小切口顺利完成手术。无1例中转开腹及术后化学性腹膜炎发生。结论:不同手术技巧应用于腹腔镜治疗卵巢皮样囊肿,具有安全、手术时间短、出血少、术后恢复快等优点,但需注意术中操作和适应证的选择。     

Contribution of celioscopy in the early diagnosis of ovarian cancers]

Four hundred and eighty-one patients with an ovarian cyst considered to be benign on the basis of clinical and ultrasonographic findings underwent diagnostic laparoscopy. All malignant tumours (9 cases) were recognized by diagnostic laparoscopy and were treated immediately via laparotomy. When a cyst was identified as being benign on laparoscopy, the diagnosis was always confirmed by histological examination. Sixty one patients (64 cysts) were treated via laparotomy immediately after laparoscopy for the following reasons: malignant or suspicious lesions (19 cases) dense adhesions or anatomical conditions making laparoscopic surgery difficult (42 cases). 420 patients (444 cysts) were treated by laparoscopic surgery with either intraperitoneal cystectomy or transparietal cystectomy. The postoperative course following laparoscopic surgery for annexal cysts was uneventful in 417 cases (3 patients developed a complication).     

A Simple Approach to Specimen Retrieval via Posterior Colpotomy Incision

Introduction:

Posterior colpotomy incision for specimen retrieval is infrequently used in gynecologic laparoscopic surgery unless a concomitant hysterectomy is performed. We aim to describe a simple and unique technique for creating the colpotomy incision and to describe intraoperative and postoperative outcomes.

Methods:

Fifty patients underwent adnexal specimen retrieval through a posterior colpotomy incision. After devascularization and detachment of the adnexal specimen, the posterior cul-de-sac was visualized. The colpotomy incision was created by introducing a 12- or 15-mm laparoscopic trocar through the vagina into the posterior vaginal fornix under direct visualization. Specimens were placed into laparoscopic bags and removed through the vagina. The colpotomy incision was closed vaginally. Charts were reviewed for intraoperative and postoperative outcomes.

Results:

Twenty-nine women underwent adnexal surgery for an adnexal mass, 14 women underwent surgery for pelvic pain, and 7 women underwent adnexal surgery for primary prevention of malignancy. The specimens removed ranged in size from 2 to 16 cm (mean 5.7). The mean time patients were under anesthesia was 103 minutes (SD 57.3). There were no operative complications related to the colpotomy incision and no cases of postoperative vaginal cellulitis or pelvic infection were reported. Only 1 woman with a prior vaginal delivery reported dyspareunia postoperatively.

Conclusion:

This simple technique for posterior colpotomy incision can easily be added to the gynecologic surgeon''s armamentarium and can be safely used for most women.     

Problems related to the cervical stump at follow-up in laparoscopic supracervical hysterectomy.

OBJECTIVES: To evaluate our experience with laparoscopic supracervical hysterectomy (LASH) and to assess the short- and medium-term outcome. METHODS: Retrospective analysis of patient and surgery characteristics from chart review and evaluation of patient satisfaction by a questionnaire. RESULTS: Forty-one patients who underwent LASH were studied with a mean length of follow-up of 27 months. Operative complications consisted of one bladder lesion and one bleeding at the trocar site. Postoperative complications were bladder atony (1), paralytic ileus (1), a pulmonary embolism (1) and vaginal hemorrhage from the colpotomy incision (1). Twenty-five percent of the patients continued to menstruate, and 10% had symptoms of discharge. Overall, 98% of the patients were satisfied with their operation. CONCLUSIONS: Although preservation of the cervix with laparoscopic hysterectomy for benign diseases was satisfactory in most of the cases, several women had complications of the remaining cervix. Special attention should be paid to the careful treatment of the cervical stump. Further prospective studies are needed to evaluate the advantages of retaining the cervix at laparoscopic hysterectomy.     

Laparoscopic-assisted vaginal subtotal hysterectomy

BACKGROUND: A novel approach in combined laparoscopic and vaginal procedures through the posterior cul-de-sac for subtotal hysterectomy is introduced. PATIENTS AND METHODS: Twenty-one women with menometrorrhagia, symptomatic adenomyosis, or uterine myomas were enrolled in this study. After laparoscopic dissection of bilateral round ligaments and adnexa, a guiding suture brought the uterine fundus down through the posterior cul-desac into the vagina via a posterior colpotomy. Subtotal hysterectomy and hemostasis of the cervical stump were then performed transvaginally by conventional techniques and equipment. RESULTS: Mean operative time, blood loss, and length of hospital stay were 111.2 +/- 28.8 minutes, 252.4 +/- 147.9 mL, and 3.2 +/- 0.9 days, respectively. No patients developed serious complications, but 1 patient had a postoperative stump infection and was treated with 2 combined antibiotics, uneventfully. CONCLUSION: A combined laparoscopic and vaginal approach in performing subtotal hysterectomy through the posterior cul-de-sac is an alternative to a purely laparoscopic approach.     

Synchronous laparoscopic sigmoid resection and hysterectomy with transvaginal specimen removal

INTRODUCTION: Laparoscopic sigmoid resection for recurrent or complicated diverticulitis and laparoscopically assisted hysterectomy for leiomyomas of the uterus are common procedures. A synchronous combination of these two interventions with the advantage of using the vaginal stump as a route for removal of the specimen has not previously been described. MATERIALS AND METHODS: We used a transvaginal extraction of the uterus and the colorectal segment, followed by a totally intra-abdominal circular stapler anastomosis. The procedure is performed via four trocar incisions, obviating the need for a laparotomy. RESULTS: Two women suffering from diverticulitis and symptomatic uterus myomatomas were treated by combined laparoscopic sigmoid resection and laparoscopically assisted transvaginal hysterectomy. Both patients had an uneventful intraoperative course. DISCUSSION: This new approach, combining two operations, is feasible and leads to almost perfect cosmetic results, cumulatively shorter hospitalization, and good patient satisfaction. Cooperation with a gynecologist as well as experience in advanced laparoscopic surgery is essential.     

A new instrument,the "Perfore-Aspirator" for laparoscopic treatment of hydatid cysts of the liver

The authors introduce a new instrument functioning as both perforator and aspirator in the laparoscopic management of hepatic hydatid cysts. Between January 1998 and January 2002, 11 laparoscopic cystotomy + partial cystectomy + drainage procedures were performed for eight consecutive patients. Eight of the cysts were located in the right lobe, and the remaining three in the left. The average diameter (+/-SD) of the cysts was 9.6 +/- 3.66 cm, and the mean age of the patients was 31.3 +/- 7.24 years. The diagnosis was confirmed by ultrasonography and/or computerized tomography. The procedure was performed with the help of three ports. The "perfore-aspirator" instrument (Bahadir Tibbi Aletler A. S., Samsun, Turkey) was introduced through the 10-mm trocar at the subcostal area, and the cystotomy procedure was done with success. Then, a partial cystectomy procedure was performed with the use of a grasper and scissors attached to an electrocautery device. The average hospitalization period was 5 +/- 1.69 days. No major morbidity or mortality was seen. All patients were treated with albendazole preoperatively and postoperatively.     

An alternative system for transvaginal removal of dermoid cyst and a comparative study with laparoscopy

The objective was to introduce a new system for transvaginal removal of ovarian cyst and to evaluate its feasibility. With a new transvaginal system, ultrasound-assisted culdotomy, and laparoscopy supported cystectomy if vaginal procedure failed. The authors conducted a retrospective review in which 35 cases using new vaginal ovarian cystectomy were compared with 40 cases of laparoscopic cystectomy for the treatment of dermoid cyst. All cystectomies were completed without conversion to laparotomy and complications. In a case from vaginal group, laparoscopy was required. No differences existed in operating time, hemoglobin decrease, and C-reactive protein value between groups. Laparoscopically supported vaginal ovarian cystectomy with ultrasound-guided culdotomy was equivalent to laparoscopic cystectomy as to invasiveness and preserved the option of a completely vaginal approach. When a presumed benign dermoid cyst is located in cul-de-sac, this operation may represent a preferable alternative to an exclusively laparoscopic or exclusively vaginal ovarian cystectomy.     

腹腔镜手术治疗巨大卵巢囊肿38例临床分析

目的 探讨腹腔镜手术治疗巨大卵巢囊肿的可行性. 方法 2002年12月～2005年10月对38例巨大卵巢囊肿行腹腔镜下囊肿剥除术或患侧附件切除术.将第2或第3个 trocar（多为肿瘤侧）直接刺入囊肿内,吸引器吸净囊液,并将囊肿提至切口处同时将切口扩大至20 mm,切除囊肿. 结果 38例均在腹腔镜下完成手术, 1例采用开放式, 37例行闭合式.卵巢囊肿剥除术28例,附件切除术10例.无手术并发症.35例术后随访1～24个月,平均10个月,盆腔检查及B超均正常. 结论腹腔镜手术治疗巨大卵巢囊肿安全可行.     

羟基磷灰石微粒人工骨修复皮样囊肿切除后额骨凹陷畸形

目的探讨羟基磷灰石微粒人工骨修复额部皮样囊肿切除后骨骼凹陷畸形的疗效及并发症。方法2000年2月-2005年5月，采用羟基磷灰石微粒人工骨修复13例额部皮样囊肿切除后的额骨凹陷畸形患者。男9例，女4例，年龄17～41岁。囊肿均在婴、幼儿期出现，囊肿大小6cm×4cm～10cm×8cm。设计发际缘或囊肿周缘的切口，完整切除皮样囊肿，并去除额骨凹陷处表面的骨膜等软组织后，以适量的羟基磷灰石微粒人工骨充填修复额骨凹陷。于术后1周，1、6个月进行临床和X线片检查。结果术后患者切口均Ⅰ期愈合，无血肿、血清肿、感染及羟基磷灰石颗粒人工骨移位等并发症发生。均获随访1～20个月，额骨凹陷完全修复，局部皮肤平滑，外观无明显凹陷；局部检查和X线片示，植入的羟基磷灰石颗粒人工骨与周围骨质结合紧密，无明显缝隙，人工骨未见移位。结论羟基磷灰石微粒人工骨充填修复皮样囊肿切除后的额骨凹陷是一种简单易行和较理想的方法。     

Laparoscopic Internal Marsupializaton for Large Nonparasitic Splenic Cysts: Effective Organ-Preserving Technique

Background Primary splenic cyst is a rare disease, and therefore there is no information regarding its optimal management. Most such cysts are classified as epithelial cysts. During the last few years, the laparoscopic approach has gained increasing acceptance in splenic surgery. We present our experience with the laparoscopic (organ-preserving) management of splenic cysts. Methods We managed 11 patients with large symptomatic nonparasitic splenic cysts from 1996 to 2006. All the patients had fullness in the left upper abdomen and a palpable mass. Preoperative diagnosis was established with ultrasonography and computed tomography. All patients were treated with either laparoscopic partial cystectomy or marsupialization. Results Seven patients had mesothelial cysts, two had epidermoid cysts, and two had pseudocysts. Nine patients did not have any problems or recurrence during an average follow-up of 29.5 months. Two patients had cyst recurrence after 14 months. Conclusion Laparoscopic organ-preserving surgery should be the goal of therapy in most cases. Total splenectomy is reserved for cases in which cyst excision cannot be done or most of the splenic tissue is replaced by the cyst. Plication of the cyst wall edges prevents the cyst walls from adhering and causing recurrence, as well as helping to control hemorrhage. Laparoscopic partial cystectomy/marsupialization is an acceptable procedure for the treatment of splenic cysts; and after short to mid-term follow-up, it seems that a reasonable rate of success is possible.     

Endoscopic surgery for mature teratoma of the ovary

Background: This study was undertaken to assess the value of laparoscopic surgery as treatment for benign mature teratomas of the ovary. Methods: A total of 70 patients treated exclusively with laparoscopic surgery for ovarian mature teratoma were studied. The tumors were either enucleated with preservation of the ovary or removed by salpingo-oophorectomy. Results: Ovary-preserving surgery was performed in 60 cases; salpingo-oophorectomy was accomplished in 10 cases. All tumors removed were histologically benign. No surgical complications were encountered throughout the series. In eight patients who underwent primary ovary-preserving surgery, a second-look laparoscopy was undertaken with virtually no pathological findings noted. Conclusions: Our findings confirm those of other authors—when performed by experienced surgeons, laparoscopic removal of ovarian mature teratomas is a safe and recommendable alternative to laparotomy. Preoperative diagnosis and intraoperative inspection of the tumor must be as thorough as possible.     

Laparoscopic management of paratubal and paraovarian cysts.

OBJECTIVES: To define the proportion, methods of diagnosis, and a simplified laparoscopic technique for treating paratubal and paraovarian cysts. METHODS: We conducted a prospective cross-sectional study in the Gynecologic Endoscopy Unit of Assiut University Hospital in Assiut, Egypt in 1853 patients undergoing video-assisted laparoscopy. Transvaginal ultrasonography (TVS) was performed to detect paratubal or paraovarian cysts. Tubal shape and patency were evaluated with hysterosalpingography (HSG) in the infertile group. Diagnostic laparoscopy was performed to confirm the diagnosis of paratubal or paraovarian cysts. Small cysts were punctured and coagulated, and larger cysts required cystectomy and extraction of the cysts by using bipolar electrosurgery. Cystectomy was preceded by endocystic visualization in all cases. The primary outcomes measured included (1) correlation of the preoperative TVS, HSG, or both of these, with the laparoscopic diagnosis; (2) estimation of the success of the laparoscopic management of paratubal cysts; (3) assessment of the value of endocystic visualization prior to cystectomy; and (4) evaluation of tubal patency after laparoscopic management. RESULTS: Laparoscopically, only 118 patients (15.7%) were proved to have paratubal or paraovarian cysts. Preoperatively, TVS confirmed paratubal or paraovarian cysts in 52 (44%) patients. Cysts less than 3 cm in size (34 cases) were treated with simple puncture and bipolar coagulation of the cyst wall, whereas larger cysts (84 cases) were treated by cystectomy. Endocystic visualization using the 4-mm rigid hysteroscope was performed in 84 (71%) patients with large cysts. Statistically significant improvement occurred in tubal patency after laparoscopic management. CONCLUSIONS: Sonographic diagnosis of not uncommon paratubal and paraovarian cysts is not always feasible and requires greater awareness and accuracy. The characteristic laparoscopic differentiation of ovarian cysts is the crossing of vessels over them. Endocystic-endoscopic visualization is a simple, valuable step prior to cystectomy. Bipolar coagulation or extraction of these cysts diagnosed at laparoscopy is easy, not time-consuming, and should be routinely performed in all cases following microsurgical laparoscopic principles.     

Transumbilical management for neonatal ovarian cysts

Background/Purpose

Since Tan and Bianchi (Br J Surg. 1986;73:399) reported umbilical incision as an access for pyloromyotomy in infantile hypertrophic pyloric stenosis, many pediatric surgeons have used this approach for a number of other procedures. Because of the long pedicle with good mobility and the frequent intraabdominal position of the neonatal ovarian cyst, we attempted to manage it via the transumbilical route.

Methods

All patients were treated under intubation general anesthesia. Semicircular infraumbilical incision was made, and the abdomen was entered through a transverse fascial incision. The partially collapsed cyst after aspiration was exteriorized through the incision for cystectomy, partial deroofing, or adnexectomy.

Results

From May 2000 to December 2006, 6 female newborns with ovarian cysts were treated via the transumbilical route. There were no complications from surgery. The operation time and duration of hospital stay were short. The cosmetic appearance after the procedure was good.

Conclusions

The initial result suggests that transumbilical management for neonatal ovarian cysts may be a good alternative procedure when laparoscopic equipment is unavailable or experienced technique is lacking.     

Experience with different methods of treatment of nonparasitic liver cysts

BACKGROUND AND AIMS: In a search for the optimal management of nonparasitic liver cysts, a study was made of the effectiveness of different methods. PATIENTS AND METHODS: Between 1 January 1982 and 15 December 2001 we treated 132 patients with nonparasitic liver cysts. In 72 patients 31 cysts were treated with enucleation, 60 with deroofing, and 24 with stitching by laparotomy; two liver resections were also performed. In a further 34 patients 36 cysts were treated with deroofing by minimally invasive surgery. In an additional 26 patients 32 cysts were treated with various interventional radiological methods. RESULTS: There was no mortality. The morbidity rate after laparotomy was significant (22.2%). The rate of recurrence after enucleation and deroofing was 6.5% and 13.8%, respectively, but there were no recurrences after stitching and liver resection. The recurrence rate following laparoscopic deroofing was 19.4%, and that following interventional radiological procedures was 50%. CONCLUSIONS: Treatment is required only if cysts are highly symptomatic or if growth is detected. Interventional radiological methods do not prove more favorable than surgery. Laparoscopic fenestration is preferred because of its low morbidity and the short period of hospitalization. Traditional surgical methods should be reserved merely for cases in which laparoscopic deroofing is not feasible.     

腹腔镜胆总管囊肿根治切除、肝管空肠吻合术

目的:探讨腹腔镜下胆道造影和胆总管囊肿根治切除、肝管空肠吻合术的可行性。方法:34例先天性胆总管囊肿患者行腹腔镜下胆道造影,胆囊和囊状胆管完全切除,经脐孔提出空肠行Roux-en-Y吻合和体内肝管空肠吻合手术。结果:胆道造影显示胆管囊状扩张24例,梭形扩张10例。33例腹腔镜下顺利完成手术,手术时间平均4.2h(3.5~6.5h);1例胰腺内胆总管远段囊肿中转开腹手术。4例合并肝管狭窄同时行胆管成形术。术后5~7d患者痊愈出院。31例获得随访,5~40个月未发生术后并发症。结论:腹腔镜下胆道造影简便实用,对指导镜下根治切除囊肿,避免损伤胆胰管连接部和处理肝内胆管狭窄有重要参考价值。