Laparoscopic microsurgical tubal reanastomosis: a preliminary study.

OBJECTIVE: To determine the effect of laparoscopic reversal of tubal sterilization on pregnancy rate. METHODS: Eight patients who underwent laparoscopic tubal reversal between March 1999 and 31 December 2001 were evaluated. RESULTS: Four of eight patients who had had laparoscopic tubal reversal became pregnant. Three have delivered; pregnancy in the fourth woman is ongoing. To date, the other four patients are still not pregnant. Two ofthese four cases have tubal patency but have not achieved pregnancy; in the other two cases, the operation was unsuccessful and tubal patency did not occur. CONCLUSION: In our preliminary study, the pregnancy rate was 50%.     

Robotic-assisted laparoscopic microsurgical tubal anastomosis: a human pilot study

OBJECTIVE: To evaluate the feasibility and safety of a robotic device to perform a laparoscopic tubal anastomosis. DESIGN: Prospective pilot study. SETTING: Tertiary care medical center. PATIENT(s): Ten patients with previous tubal ligations underwent laparoscopic tubal ligation reversal using a robotic suturing device. INTERVENTION(s): Tubal surgery was performed with a robotic system. A two-layered closure was used for all tubes. Four stitches of 8-0 polygalactin sutures were used for each layer. MAIN OUTCOME MEASURE(s): Tubal patency; secondary measures were pregnancy rates, complications, and operative time. RESULT(s): The procedure was completed successfully in all 10 patients. No patient required conversion to an open procedure. The mean time (+/-SD) required to complete the anastomosis of both tubes was 159 +/- 33.8 minutes. Chromotubation at the end of the procedure showed patency in all tubes anastomosed. A postoperative hysterosalpingogram 6 weeks after surgery demonstrated patency in 17 of the 19 (89%) tubes anastomosed. There have been five pregnancies so far. There were no complications. CONCLUSION(s): Robotic technology can be used safely to create laparoscopic microsurgical anastomoses with adequate patency rates. Robotic technology has the potential to make laparoscopic microsuturing easier.     

Robotically assisted laparoscopic myomectomy: a Canadian experience

ObjectiveTo compare operative and immediate postoperative outcomes of robotically assisted laparoscopic myomectomy (RALM) and open myomectomy.MethodsWe conducted a retrospective review of 38 cases of RALM performed in women of reproductive age with symptomatic uterine fibroids between October 2008 and February 2011. Twenty-one cases of open myomectomy were used as historical controls. Operative and immediate postoperative outcomes were compared. Data analysis was performed using Student t test, chisquare test, and analysis of covariance where appropriate.ResultsThe two groups were comparable in age, body mass index, parity, and symptoms. Up to 12 fibroids were resected robotically with a mean diameter of 9.1 ± 2.0 cm and a mean weight of 389 ± 170 g (range 73 to 900 g). RALM was associated with less blood loss (decrease in hemoglobin concentration 25.6 ± 12.0g/L) than open myomectomy (37.7 ± 20.1 g/L) (P = 0.018). Adjusting for baseline levels, postoperative hemoglobin levels were 99 g/L and 88 g/L in the robotic and open groups, respectively ((P = 0.005). RALM was associated with shorter hospitalization (1.2 ± 0.5 vs. 2.5 ± 0.6 days, (P < 0.001) and longer operating times (189.7 ± 71.5 vs. 92.5 ± 33.0 minutes, (P < 0.001). Three patients in the open myomectomy group and one in the robotic group required blood transfusion. One patient in the robotic group developed lumbar plexopathy postoperatively.ConclusionRobotically assisted laparoscopic myomectomy is associated with less blood loss and shorter hospital stay than myomectomy by laparotomy. Accumulating evidence of the risks and benefits of RALM will contribute to enhancing access to this technology on the part of women and their surgeons.     

Robotically assisted fluorescence-guided lymph node mapping with ICG for gynecologic malignancies: a feasibility study

Objective

Traditional techniques of sentinel lymph node (SLN) mapping for endometrial and cervical cancer present challenges which may be overcome with newer technologies such as near infrared (NIR) imaging of the fluorescent dye Indocyanine green (ICG). We performed a feasibility and dose-finding study to define the dose of ICG required to identify pelvic and para-aortic sentinel lymph nodes with robotically assisted endoscopic NIR imaging after cervical injection.

Methods

20 subjects with cervical or endometrial carcinoma were prospectively enrolled for SLN mapping. ICG was injected into the cervical stroma at 3 o'clock and 9 o'clock Data was collected for the number of nodes identified, the location of SLN's, the duration of procedure and the pathology characteristics of the SLN's compared to the non-sentinel lymph nodes.

Results

20 subjects received cervical injection with at least one SLN observed in 17 subjects. 15 of the 17 subjects who received 1 mg injections of ICG mapped a SLN for an observed detection rate of 88% (95% CI is (64%,99%)). A median of 4.5 SLN's was identified per patient. Three patients had lymphatic metastases, one of whom had a positive SLN. No adverse events were identified.

Conclusions

A 1 mg cervical injection of ICG identified a SLN in 88% of patients (95% CI is (64%, 99%)). Robotically assisted fluorescence imaging is a feasible, safe, time efficient and reliable method for lymphatic mapping in early stage cervical and endometrial cancer.     

Laparoscopic non-microsurgical tubal reanastomosis: A retrospective cohort study

Abstract

Objective To determine the pregnancy rate achieved through laparoscopic tubal reanastomosis using only standard 5 mm laparoscopic instruments and standard suturing material.

Methods Data from 100 consecutive laparoscopic tubal reanastomosis procedures done between September 2002 and September 2010 were retrospectively analysed. All procedures were performed by the same surgeon using standard 5 mm laparoscopic instruments and with the placing of three or four sutures of standard polyglycan 4/0 suturing material. The main outcome measures were: (intrauterine) pregnancy rate and live birth rate before and after 40 years of age, and tubal patency rate.

Results Six patients had no active child wish and six others were lost to follow-up, thus leaving 88 of 100 patients for evaluation. Fifty-eight of these conceived, giving a total pregnancy rate (PR) of 66%. The PR in women younger than 40 years was significantly greater than that achieved by those aged 40 or more (73% vs. 29%, p = 0.001).

Conclusions Laparoscopic tubal reanastomosis with standard 5 mm laparoscopic instruments results in a satisfactory pregnancy rate.

Chinese Abstract

摘要：

目的 测定那些仅采用标准5毫米腹腔镜的手术器械及标准缝合材料进行输卵管复通术的患者的受孕率。方法 本研究对2002年9月至2010年9月之间进行输卵管复通术的患者进行了回顾性的分析。所有患者均由相同的外科医师采用标准的5毫米腹腔镜手术器械,并且采用三至四个4/0标准多聚糖缝合线。主要结果评定:40岁左右患者(宫内)妊娠率和活产率,以及输卵管通畅程度。结果 在100位患者中,有6例患者没有妊娠的意愿,6位患者失访,因此我们对剩余的88位患者进行了评估。其中58位患者妊娠,总妊娠率为66%。40岁以下的年轻女性的受孕率明显高于那些40岁以上的女性（73%比29%,P<0.001）结论 采用5毫米标准腹腔镜手术器械进行的腹腔镜下输卵管复通术可以取得满意的妊娠效果。     

Characteristics of women who considered or obtained tubal reanastomosis: results from a prospective study of tubal sterilization

The Collaborative Review of Sterilization is a prospective study of women undergoing tubal sterilization at selected medical centers in the United States. This analysis examined 5817 study participants who were asked whether they had sought information on tubal reanastomosis after their sterilizations and whether they had actually obtained reanastomosis surgery. Characteristics that predicted the likelihood of seeking reanastomosis information were examined in multivariate, logistic regression models that included age, race, number of living children, history of abortion, education, timing of sterilization in relation to pregnancy, initial marital status, and change in marital status. Among the women studied, 6.2% reported that they had sought information on reanastomosis. Women who were younger than 30 years old at the time of sterilization were twice as likely to seek such information as women aged 30-34, and women who had experienced changes in martial status after sterilization were 2.8 times as likely to seek information as women with unchanged marital status. Thirteen women had actually obtained reanastomosis. Compared with the overall study population, these women were more likely to be white, to have lower gravidity, to be younger, and to have experienced changes in marital status.     

Robot-assisted tubal reanastomosis: Initial experience in a single institution

ObjectiveTo assess surgical outcomes for robot-assisted tubal reanastomosis in a single institution.Materials and MethodsBetween March 2009 and January 2010, 10 patients underwent robot-assisted tubal ligation reversal (TLR) with a da Vinci S surgical system. Patient demographic data, including operative times, operative and postoperative complications, hospital stay, conversion to laparotomy and pregnancy rates were recorded.ResultsMean age and body mass index for the patients were 37.7 (35–42) years and 28.9 (23.9–36.3) kg/m², respectively. The mean console time was 102.5 min and the mean total operation time was 130.6 (102–164) min. The mean hospital stay was 1.2 (1–2) days. There were no significant intra-operative or early-postoperative complications. All surgeries were completed robotically with no conversion to laparotomy. There were seven subsequent pregnancies in the study participants, representing a pregnancy rate of 70%, of which five were intrauterine pregnancies, one was an ectopic pregnancy, and one was an abortus.ConclusionRobot-assisted TLR is safe and feasible. This procedure may facilitate minimally invasive treatment for patients who want to regain their fertility without the aid of artificial reproductive techniques.     

A successful microsurgical reanastomosis program in a community hospital

Microsurgical tubal reversal (MTR) can now be performed at the community-hospital level with excellent results if meticulous attention is paid to intraoperative surgical details. An initial series of 15 patients underwent MTR, with a term pregnancy rate of 87%. No postoperative complications occurred, and no postoperative hydroperturbations or second-look laparoscopies were performed.     

Robotically assisted laparoscopic hysterectomy versus total abdominal hysterectomy and lymphadenectomy for endometrial cancer

ObjectiveTo compare surgical morbidity and clinical–pathologic factors for patients with endometrial cancer (EC) undergoing robotic-assisted laparoscopic hysterectomy (RALH) versus total abdominal hysterectomy (TAH) with aortic and/or pelvic lymphadenectomy (LA).MethodsDuring the first 14 months of a robotics surgical program, 56 patients with EC were scheduled to undergo RALH with LA. Cases were analyzed for operative (op) time, estimated blood loss (EBL), transfusion, intra- and post-op complications, surgical–pathologic data, patient demographics and length of stay (LOS). Data was compared to 106 serially treated patients with EC who underwent TAH with LA immediately prior to initiation of our robotics program.ResultsThree robotic cases (5.4%) were converted to TAH secondary to intra-op factors. FIGO stages for RALH vs. TAH were: stage I (82 vs. 69%), stage II (7 vs. 7.5%) and stage III (11 vs. 21.5%). Patients' mean age was 59 ± 10 vs. 63 ± 11 years (p = 0.05) and body mass index (BMI) was 29 ± 6.5 vs. 34 ± 9 kg/m² (p = 0.0001) for the robotic and open groups, respectively. Severe medical co-morbidities affected 5.4% of robotic patients compared to 8.5% of open cases (p > 0.05). Comparing RALH and TAH, mean op time was 177 ± 55 vs.79 ± 17 min (p = 0.0001), EBL was 105 ± 77 vs. 241 ± 115 ml (p < 0.0001), transfusion was 0 vs. 8.5% (p = 0.005), and LOS was 1.0 ± 0.5 vs. 3.2 ± 1.0 days (p < 0.0001). Robotic patients incurred a 3.6% major peri-operative complication rate while women undergoing open procedures had an incidence of 20.8% (p = 0.007). Total lymph node count was 19 ± 13 nodes for robotic cases vs. 18 ± 10 nodes obtained from open hysterectomy patients.ConclusionsPatients with EC who underwent RALH with LA during the first year of our robotics program were younger, thinner and had less cardio-pulmonary illness than patients previously treated with TAH and LA. LOS, EBL and peri-op complication rates were significantly lower for the robotic cohort.     

Laparoscopic microsurgical tubal re-anastomosis: the two-stitch technique

The objective of this study was to determine the effectiveness of the two-stitch unilateral laparoscopic sterilization reversal. Thirty-three patients who had undergone unilateral laparoscopic sterilization reversal between December 2001 and October 2006 were examined. Twenty patients (60.6%) who had had laparoscopic unilateral tubal sterilization reversal achieved an ongoing pregnancy within 1 year of the operation. In vitro fertilization (IVF) was recommended to the other 13 patients, including one patient (3%) who had an ectopic pregnancy. In conclusion, in our study, the pregnancy rate after unilateral two-stitch laparoscopic tubal reversal was 60.6%. In this IVF era, tubal anastomosis will become more popular, causing fewer women to resort to IVF and experience a completely natural conception, making surgery complementary to ART. The number of surgeons skilled in laparoscopic tubal surgery must, therefore, be increased.     

Risk of adhesions formation following microsurgical monopolar laparoscopic ovarian drilling: a comparative study

The objective of the study was to determine the prevalence, extent, and location of adhesion formation following microsurgical monopolar laparoscopic ovarian drilling (LOD) among fertile and infertile women with clomiphene-resistant polycystic ovaries (PCO). The design was a longitudinal cohort follow-up study. The study was performed at the endoscopic unit of a tertiary university center. Three hundred and forty-seven patients with PCO were scheduled for LOD as a treatment option for clomiphene-resistant anovulation. Microsurgical monopolar LOD was performed in all cases. Two hundred and forty-six patients without possible additional predisposing factor for postoperative adhesion formation were followed up. To assess the sole effect of LOD on adhesion formation, only 51 eligible patients were classified into two groups; Group A comprised 22 women who conceived within 6 months following LOD and subjected to cesarean section, while group B included 29 women who failed to conceive over the same period of time and subjected to second-look laparoscopy. The main outcome measure was an evaluation of the prevalence, side, site, and severity of pelvic adhesions following microsurgical monopolar LOD. In total, adhesions were diagnosed in 40 cases (78.4%). Adhesions were diagnosed in 15 cases (68.1%) and 25 cases (86.2%) in groups A and B, respectively, without a statistically significant difference (p = 0.21). Periovarian adhesions were diagnosed in 47/51 (92%) of cases in both groups. In 29 (56.8%) cases in both groups, adhesions were diagnosed on both sides (right and left adnexae) divided as eight (36.3%) and 21 (72.4%) in groups A and B, respectively, with a statistically significant difference (p = 0.01). The documented high prevalence of adhesions among infertile as well as women who conceived following LOD is an added evidence to the established risk of post-LOD adhesion formation. Following microsurgical principles would minimize the risk of these adhesions except periovarian adhesions. There is a bad need for studies on more refinement of LOD to make it as less adhesiogenic procedure as possible.     

Ferti-test. A simple method for tubal function diagnosis: feasibility study

BACKGROUND: To indicate the simplicity and the feasibility of this new diagnostic technique for infertility investigation. Ferti-test is a technique which combines dye-test and pelvic post coital test, using inexpensive surgical material. Ferti-test allows to perform laparoscopy only in very necessary cases, without loosing diagnostic quality. METHODS: Up to September 2001, 30 patients aged from 24 to 46 years, with infertile problems were enrolled. All the patients, in a preovulatory period, underwent dye-test combined with pPCT. Before the operation, all the patients were investigated for endocrinological assessment; an evaluation of sperm liquid in all the partners and a PCT have been carried out. All these data were organized in a specific diagram, which allowed to recognize the normality or the specific class of pathology of infertile couple. RESULTS: The purpose of this study is to remark the simplicity and the feasibility of this new diagnostic method. In our study, no patients who underwent dye-test and pelvic PCT had any complications. Only 7 patients with negative dye-test and pelvic PCT underwent diagnostic laparoscopy. CONCLUSIONS: The results of this study indicate that Ferti-test is an effective and reliable technique for the first level evaluation in infertile couples. Ferti-test is well tolerated and requires minimal cost. With Ferti-test it is possible to screen the patients who actually need laparoscopy and to reduce risks and costs.     

Total laparoscopic hysterectomy and early discharge: satisfaction and feasibility study

STUDY OBJECTIVE: Whether, after laparoscopic hysterectomy (LH), selected patients may be safely and comfortably discharged on postoperative day 1 (day after surgery) using specific anesthesia and analgesia protocols that included Post Anesthetic Discharge Scoring System. DESIGN: A prospective feasibility pilot study (Canadian Task Force classification II-3). SETTING: A French tertiary care hospital. PATIENTS: A total of 35 patients who underwent total LH were selected using preestablished criteria based on age, surgical history, place of residence, and capacity to follow instructions. INTERVENTIONS: All patients had a telephone call the second and seventh day after surgery. MEASUREMENTS AND MAIN RESULTS: Of 35 patients, 34 (97.1%) left the hospital the day after surgery. One patient was not discharged on surgeon's instructions, because of technical difficulties during the procedure. Two patients (6.7%) required readmission because of complications. The first patient required hospitalization for vesicovaginal fistula at day 10 and had to undergo laparoscopic treatment of the fistula. The second consulted for hyperthermia at day 4 with suggestion of cuff cellulitis, and was discharged after 2 days of antibiotic treatment. Of 35 women, 34 (97.1%) were satisfied with the procedure and all would recommend it to other patients. CONCLUSION: Using our protocol for analgesia, anesthesia, and early discharge (24 hours after surgery) may be safely proposed after total LH in selected patients. Satisfaction rate of patients on postoperative days 7 and 30 was very high.