Major vascular injuries during gynecologic laparoscopy

Background:This study was undertaken to report our experience with major vascular injuries in gynecologic laparoscopy in order to specify the circumstances under which they occurred, the means of diagnosis, the risk factors, and the means for prevention.Study Design:Retrospective case review study.Results:Seventeen patients with 21 major vascular injuries were identified. The average age of the patients was 33.8 ± 11.6 years, and the mean body index mass was 21.6 ± 3.08 kg/m². Three of four of the accidents occurred during the set-up phase of laparoscopy (13 cases; 76.5%), and in 4 cases (23.5%) the accident occurred during the laparoscopic surgery procedure. Eleven (84.6%) of the complications occurring during the set-up phase were secondary to insertion of the umbilical trocar and 2 (15.4%) to insertion of the needle used to create the pneumoperitoneum (P-needle). Half (6 cases; 54.5%) of the major vascular injuries secondary to insertion of the umbilical trocar were observed when reusable trocars were used. In every case, the diagnosis was made during the operation. Two patients died, and two others presented a serious complication (phlebitis; acute ischemia requiring reoperation).Conclusions:Major vascular injuries are rare but serious complications of laparoscopic surgery. Prevention of these accidents relies on the surgeon’s experience and scrupulous respect of the safety rules. In the vast majority of cases, it is necessary to convert to laparotomy immediately, calling in a vascular surgeon.     

Upper quadrant access for urologic laparoscopy

Initial access into the peritoneum and establishing pneumoperitoneum are required for laparoscopy. Various techniques have been described to achieve insufflation and place trocars. We describe our method of initial entry into the upper quadrant and subsequent incorporation of this site as a working port during upper urinary tract laparoscopy. This is an easy and safe means of entering the peritoneum, even after prior surgery, and provides a functional trocar for retraction and dissection.     

Insufflation techniques in gynecologic laparoscopy

Our objectives were to assess the safety and efficacy of different insufflation methods in women undergoing laparoscopy and to develop a model for selection of the appropriate insufflation technique based on the patient's characteristics and surgeon's experience. We performed a retrospective analysis of laparoscopic procedures on 3086 women over a 13-year period at the University of Louisville Hospital, Louisville, KY. All laparoscopic procedures were performed on an outpatient basis by residents under faculty supervision. Five different insufflation techniques were evaluated: standard transumbilical insufflation, open laparoscopy, transuterine insufflation, subcostal insufflation, and direct trocar insertion technique. Body mass index and previous abdominal surgeries were identified as the most important factors in the selection of the most successful insufflation method based on the surgeon's experience, using data mining techniques. During the first insufflation attempt, we were successful at achieving a pneumoperitoneum 94.7% of the time. This number increased to 98.1% when we switched to a second alternative insufflation method. In all, there were 5 complications out of 3086 patients (0.16%) after all insufflation techniques.     

Robot-assisted laparoscopy in gynecologic oncology

Objectives  The aim of this prospective study was to evaluate the feasibility and the outcome of gynaecological cancer surgery with the Da Vinci S surgical system (Intuitive Surgical). Methods  From February 2007 to September 2007, 28 patients underwent 32 gynaecological procedures in a single centre. Surgical procedures consisted of total hysterectomy, bilateral oophorectomy, and pelvic and/or lombo-aortic lymphadenectomy. In all cases, surgery was performed using both laparoscopic and robot-assisted laparoscopic techniques. In this heterogeneous series, a subgroup of 12 patients treated for advanced cervical cancer was compared with a retrospective series of 20 patients who underwent the same surgical procedure by laparotomy. Results  Mean age of the entire population was 52.5 years (range 25–72 years) and mean body mass index (BMI) was 25 kg/m² (range 18–40 kg/m²). Indications for surgery were cervical cancer in 21 cases, endometrial cancer in 7 cases, ovarian cancer in 1 case and cervical dysplasia in 3 cases. Median operating time was 180 min (mean 175.25 min, range 80–360 min) and median estimated blood loss was 110 cc (range 0–400 cc); no transfusions were necessary. No perioperative complications were observed and median time of hospitalisation was 3 days (mean 3.9 days, range 2–8 days). In the subgroup of 12 advanced cervical cancer a significant difference was observed in terms of hospital stay compared with laparotomy; no difference was observed concerning operative time. Fewer complications were observed with laparotomy (33% versus 25%) but more serious complications than with robot-assisted laparoscopy. Conclusion  As suggested in the literature, the use of robot-assisted laparoscopy leads to less intraoperative blood loss, less post operative pain and shorter hospital stays compared with those treated by more traditional surgical approaches. Despite the need for more extensive studies, robot-assisted surgery seems to represent a similar technological evolution as the laparoscopic approach 50 years ago.     

腹腔镜手术在妇科疾病诊治中的应用

目的:探讨腹腔镜手术在妇科疾病诊治中的临床应用价值。方法:回顾性分析我科8个月来115例妇科疾病患者实施腹腔镜手术的临床资料,不同的疾病采用不同的手术方式。结果:全部手术均获成功,成功率100%,术中出血2～800ml,平均61.54ml。结论:腹腔镜手术治疗妇科疾病其适应证与开腹手术相同,对需要保留生育功能的患者尤为适用。与开腹手术相比具有患者创伤小、恢复快、并发症少等优点。     

Noninvasive hemodynamic monitoring in gynecologic laparoscopy

A new non-invasive haemodynamic monitoring technique was investigated on twenty female patients submitted to gynaecological laparoscopy under general anaesthesia. Continuous aortic output was measured with an echo-Doppler oesophageal probe specially developed by the authors. Peritoneal insufflation was performed with an average of 4 +/- 0.750 l CO2 at an average insufflation rate of 0.666 l X min-1; intraperitoneal pressure increased on average by 11.57 +/- 1.60 mmHg during insufflation. Aortic output changes were related to changes in the patient's position. In initial horizontal dorsal decubitus position, average aortic output was 2.83 +/- 0.642 l X min-1. Trendelenburg position (28 +/- 2 degrees) induced a transient 9.54% increase (p less than 0.05), while a return to the horizontal position was marked by an 11.3% increase (p less than 0.01) of the aortic output. No significant change was observed during insufflation and exsufflation (-2.13 and -5.3% respectively). Mean arterial pressure rose by 16.4% after insufflation (initial values: 90 +/- 15.08 mmHg; p less than 0.01). Total vascular systemic resistances were significantly higher at the end of insufflation (2.999 +/- 376 dyn X cm X s-5; + 18.04%; p less than 0.05). Heart rate did not change significantly. Aortic output monitoring with this non-invasive, easy-to-handle technique enabled early detection of haemodynamic changes during laparoscopy. These changes frequently preceded significant blood pressure or heart rate variations.     

Making the transition from standard gynecologic laparoscopy to robotic laparoscopy.

OBJECTIVES: To determine the feasibility of using a simple procedure, a bilateral tubal ligation, as a transition procedure when adopting robotic laparoscopy for gynecologic surgery. METHOD: To obtain robotic credentialing and gain experience with the robotic system, the surgeons first went through robotic training, then 4 women desiring permanent sterilization had robotically assisted laparoscopic bilateral tubal ligations performed, using the Parkland method. RESULTS: Total operating room time varied from 1 hour 25 minutes to 2 hours 31 minutes. Improvement in operating time for each surgeon was noted with each successive case. Best times in robotic cases were similar to those of standard laparoscopy. CONCLUSION: Robotically assisted laparoscopic tubal ligation using the Parkland method is a satisfactory procedure to provide transition for gynecologic surgeons and operating room personnel to gynecologic robotic surgery.     

Right upper quadrant swelling due to Leiomyosarcoma

Reports of leiomyosarcoma occurring in the extremely elderly are quite rare. We describe a case of leiomyosarcoma in an 85-year-old patient and discuss magnetic resonance findings.     

Splenic protection in left upper quadrant operations

Splenectomy produces significant immediate and long-term risks for the patient, and there is general agreement that it should be reserved for clear-cut unavoidable indications. However, accidental injury to the spleen in the course of another operation (incidental splenectomy,) accounts for almost 40% of splenectomies in some series. Incidental splenectomy is most likely to occur in left upper quadrant operations such as proximal gastric vagotomy, or in colonic operations involving mobilization of the splenic flexure. Incidental splenectomy rates of between 2% and 9% have been reported in association with these procedures. The results of an operative strategy of specific protection of the spleen as the first step in a left upper quadrant operation ('defusing' the spleen) are reported. It was not necessary to remove the spleen because of accidental injury in 417 consecutive operations over a 5 year period after implementation of this policy. There were several minor splenic capsular tears which were controlled by intraoperative haemostatic measures. There were no cases of postoperative splenic bleeding. 'Defusing' the spleen is an effective step in preventing splenic injury in left upper quadrant operations.     

Evaluation of anesthesia with ketamine-diazepam in gynecologic laparoscopy

The group of 127 women is presented in which laparoscopy was carried out under ketamine-diazepam anaesthesia. The anaesthesia was evaluated from the anaesthetic and gynaecologic point of view. Additionally, the intraoperative and postoperative sensations of patients were evaluated. The results obtained show that the use of the ketamine-diazepam combination alone can provide good anaesthesia for laparoscopy.     

免气腹腹腔镜用于妇科手术的临床价值

目的:探讨免气腹腹腔镜在妇科手术领域的应用价值。方法:回顾分析2006年以来在妇科领域施行免气腹腹腔镜手术的疗效,并与同期气腹法腹腔镜对比。结果:两种方法的手术时间、术中出血量、术后肛门排气时间、体温及腹胀时间差异有统计学意义。结论:免气腹腹腔镜手术在术中通气、血液动力学及术后疼痛等方面均明显优于气腹法,可作为腹腔镜手术发展的一个方向。