Decreasing strain on the surgeon in gynecologic minimally invasive surgery by using semi-active robotics

Objective

To assess the advantages of a surgeon-controlled robotic endoscope holder in gynecologic minimally invasive solo-surgery as compared with conventional assistance with a second surgeon.

Methods

One hundred gynecologic laparoscopies were consecutively allocated to surgery with either a robot as the surgical assistant or a conventional assistant surgeon. Total operation time, image stability, and frequency of corrective maneuvers of the camera, in addition to the surgeon's satisfaction regarding the ergonomics of the intervention, were recorded. All interventions were performed by the same surgeon. All laparoscopic surgery was classified as either easy or advanced surgery.

Results

The image stability score was significantly higher (10 vs 7; P < 0.001) and fewer corrective maneuvers of the robotic endoscope were necessary (1 vs 5; P < 0.001) with the robotic laparoscope holder; in addition, the surgeon recorded a significantly higher satisfaction score for the ergonomics of the semi-active robot (10 vs 7; P < 0.001).

Conclusion

The robot does not prolong total operation time and increases the surgeon's comfort by improving image stability and laparoscope handling. It could provide major benefit, especially in complex gynecologic laparoscopic surgery.     

Low-dose propofol to prevent nausea and vomiting after laparoscopic surgery

Objective

To evaluate the efficacy of administering a low dose of propofol at the end of surgery in preventing postoperative nausea/vomiting in women undergoing gynecologic laparoscopic surgery.

Method

In a randomized, double-blind, placebo-controlled study, 90 patients received intravenous injections of a placebo or propofol at 2 different low doses, 0.25 mg/kg or 0.5 mg/kg. All episodes of nausea, retching, or vomiting were then recorded for 24 hours.

Results

The percentages of patients experiencing nausea, retching, or vomiting were 67% in the placebo group, 60% in the propofol 0.25 mg/kg group (P = 0.39), and 33% in the propofol 0.5 mg/kg group (P = 0.009). A significant difference in the rates of nausea/vomiting was found between the 2 propofol groups (P = 0.03). No adverse events attributed to the study drug were observed.

Conclusion

Prophylactic therapy with 0.5 mg/kg of propofol was found to be effective in preventing nausea/vomiting in patients undergoing gynecologic laparoscopic surgery.     

Dual-console robotic surgery compared to laparoscopic surgery with respect to surgical outcomes in a gynecologic oncology fellowship program

Objective

Minimally invasive surgical techniques decrease surgical morbidity and recovery time. Studies demonstrate similar surgical outcomes comparing robotic to laparoscopic surgery. These studies have not accounted for the incorporation of fellow education. With the dual-console da Vinci Si Surgical System®, a two surgeon approach could be performed. We sought to compare surgical outcomes at a gynecologic oncology fellowship program of traditional laparoscopic to robotic surgeries using the dual-console system.

Methods

We identified patients who underwent laparoscopic or robotic surgery performed by a gynecologic oncologist from November 2009-November 2010. Robotic surgeries were conducted using the dual-console, utilizing a two surgeon approach. Surgeries involved a staff physician with a gynecologic oncology fellow. Statistical analysis was performed using student t-test and chi-squared analysis.

Results

A total of 222 cases were identified. Cases were analyzed in groups: all cases identified, all cancer cases, and endometrial cancer cases only. When analyzing all cases, no statistical difference was noted in total operating room time (172 vs. 175 min; p = 0.6), pelvic lymph nodes removed (10.1 vs. 9.6; p = 0.69), para-aortic lymph nodes dissected (3.7 vs. 3.8; p = 0.91), or length of stay (1.5 vs. 1.3 days; p = 0.3). There was a significant difference in total surgical time (131 vs.110 min; p < 0.0001) and EBL (157 vs.94 ml; p < 0.0001), favoring robotic surgery. When analyzing all cancer cases, the advantage in total surgical time for robotic surgery was lost. Complications were similar between cohorts.

Conclusion

Incorporating fellow education into robotic surgery does not adversely affect outcomes when compared to traditional laparoscopic surgery.     

Quality of laparoscopic radical hysterectomy in developing countries: a comparison of surgical and oncologic outcomes between a comprehensive cancer center in the United States and a cancer center in Colombia

Objective

To help determine whether global collaborations for prospective gynecologic surgery trials should include hospitals in developing countries, we compared surgical and oncologic outcomes of patients undergoing laparoscopic radical hysterectomy at a large comprehensive cancer center in the United States and a cancer center in Colombia.

Methods

Records of the first 50 consecutive patients who underwent laparoscopic radical hysterectomy at The University of Texas MD Anderson Cancer Center in Houston (between April 2004 and July 2007) and the first 50 consecutive patients who underwent the same procedure at the Instituto de Cancerología-Clínica las Américas in Medellín (between December 2008 and October 2010) were retrospectively reviewed. Surgical and oncologic outcomes were compared between the 2 groups.

Results

There was no significant difference in median patient age (US 41.9 years [range 23-73] vs. Colombia 44.5 years [range 24-75], P = 0.09). Patients in Colombia had a lower median body mass index than patients in the US (24.4 kg/m² vs. 28.7 kg/m², P = 0.002). Compared to patients treated in Colombia, patients who underwent surgery in the US had a greater median estimated blood loss (200 mL vs. 79 mL, P < 0.001), longer median operative time (328.5 min vs. 235 min, P < 0.001), and longer postoperative hospital stay (2 days vs. 1 day, P < 0.001).

Conclusions

Surgical and oncologic outcomes of laparoscopic radical hysterectomy were not worse at a cancer center in a developing country than at a large comprehensive cancer center in the United States. These results support consideration of developing countries for inclusion in collaborations for prospective surgical studies.     

Evaluation of laparoscopic management of gynecologic emergencies by residents

Objective

To evaluate the feasibility of laparoscopic management of women with gynecologic emergencies by the residents and the chief resident in an organized resident training program.

Methods

A retrospective study of patients with gynecologic emergencies who underwent laparoscopic surgery between January 1, 1999, and May 31, 2006 was done.

Results

For the 369 patients included, the mean operative time of 74 ± 31.35 minutes was significantly increased by advanced patient age (P < 0.001), pelvic inflammatory disease with or without tubo-ovarian abscess (PID ± TOA) (P < 0.050), the first semester of chief residency (P < 0.050), and conversion to laparotomy (P < 0.001). Mean length of hospital stay was 40 ± 24 hours. Factors such as advanced patient age (P < 0.001), prolonged length of surgery (P < 0.001), PID ± TOA (P < 0.001), first semester of chief residency (P < 0.050), conversion to laparotomy (P < 0.001), and blood transfusion (P < 0.050) significantly increased the length of hospital stay. The conversion rate to laparotomy was 4.6% (n = 17), and it was significantly associated with advanced women age (OR 1.11; 95% CI, 1.05-1.17, P < 0.001) and PID ± TOA (OR 6.04; 95%CI, 2.17-16.62, P < 0.001). Postoperative complications were recorded in 3 (0.81%) patients.

Conclusion

Laparoscopic management of gynecologic emergencies by senior residents and a chief resident within an organized resident training program is feasible. These results reinforce the relevance of a well-structured residency endoscopic training program.     

Outcomes of patients with gynecologic malignancies undergoing video-assisted thoracoscopic surgery (VATS) and pleurodesis for malignant pleural effusion

Objectives

We evaluated the indications and outcomes of patients with known gynecologic malignancies that underwent video-assisted thoracoscopic surgery (VATS) and pleurodesis for malignant pleural effusion.

Methods

After IRB approval was obtained, a retrospective study of patients with gynecologic malignancies who underwent planned VATS/pleurodesis between 1/2000 and 7/2010 was performed. Abstracted data included demographics, diagnosis, disease status, treatment history, indication for VATS, complications, and outcomes.

Results

Forty-two patients with a gynecologic malignancy underwent VATS/pleurodesis. Median age was 63 years. Twenty-nine patients (69%) had ovarian cancer. Fifty-seven percent had recurrent disease at the time of VATS and 57% were undergoing chemotherapy at the time of VATS. Eight patients (19%) underwent perioperative VATS to improve pulmonary status. Seven patients (17%) underwent a palliative VATS. The median length of stay was 7 days (range 1-53). Sixty-two percent had gross disease noted at the time of VATS. A mean of 1650 cc of fluid was drained at time of surgery (range 300-4500), and the majority (88%) of patients had a talc pleurodesis performed. Seven patients (17%) were readmitted within 30 days; 6 were for complications unrelated to their VATS. One patient was readmitted with hospital-acquired pneumonia and died during readmission. Median time to death after VATS was 104 days (range 4-1062). Patients who underwent a perioperative VATS had the longest survival (845 days).

Conclusion

Patients with gynecologic malignancies may require a VATS/pleurodesis for symptomatic pleural effusions. This procedure appears to be safe and effective in this patient population.     

Impact of surgeon volume on patient safety in laparoscopic gynecologic surgery

Objective

To determine the impact of surgeon volume on patient outcomes in gynecologic laparoscopic surgery.

Methods

We reviewed all patients who underwent a laparoscopic procedure between January 2000 and December 2008. Surgeons were divided into 3 groups based on surgical volume. The mean number of surgeries per year was calculated for each surgeon. Means were categorized into 3 groups. The low-, medium-, and high-volume surgeon groups were compared with respect to level of surgical complexity and intraoperative and postoperative complications.

Results

The study included 829 surgeries. Low-volume surgeons (n = 5) performed 5 (31.3%) low-complexity, 10 (62.5%) intermediate-complexity, and 1 (6.3%) high-complexity procedures. Medium-volume surgeons (n = 6) performed 26 (11.1%) low-complexity, 203 (86.8%) intermediate-complexity, and 5 (2.1%) high-complexity procedures. High-volume surgeons (n = 5) performed 47 (8.1%) low-complexity, 439 (75.8%) intermediate-complexity, and 93 (16.1%) high-complexity procedures. The distribution of surgical complexity was significantly different between the 3 groups of surgeons defined by volume (P < 0.001). Conversion rates were higher for low-volume surgeons when compared to high-volume surgeons (18.8% vs. 5.2%; P = 0.04). Similarly, overall complication rates (< 30 days) were higher for low-volume surgeons compared to high-volume surgeons (31.3% vs. 17%, P = 0.003). Mean length of hospital stay was longer for low-volume (2.4 days) than for medium-volume (1.3 days) and high-volume surgeons (1.6 days) (P = 0.003).

Conclusion

High- and medium-volume gynecologic laparoscopists performed a greater proportion of intermediate- and high-complexity procedures than did low-volume surgeons. High-volume surgeons have a lower rate of conversions, overall postoperative complications, and shorter mean length of hospital stay when compared to low volume surgeons.     

Impact of smoking on perioperative pulmonary and upper respiratory complications after laparoscopic gynecologic surgery

Objective

To determine the impact of smoking on the rate of pulmonary and upper respiratory complications following laparoscopic gynecologic surgery.

Methods

We retrospectively identified all patients who underwent laparoscopic gynecologic surgery at one institution between January 2000 and January 2009. Pulmonary and upper respiratory complications were defined as atelectasis, pneumonia, upper respiratory infection, acute respiratory failure, hypoxemia, pneumothorax, or pneumomediastinum occurring within 30 days after surgery

Results

Nine hundred three patients underwent attempt at laparoscopic surgery. Fifty-four were excluded because of conversion to laparotomy and 31 because of insufficient data. Of the 818 patients included, 356 (43%) had cancer. A total of 576 (70%) patients were never smokers, 156 (19%) were past smokers, and 86 (10%) were current smokers (smoked within 6 weeks before surgery). These three groups were similar with regard to median body mass index, operative time, and length of hospital stay. Compared to never and past smokers, current smokers were more likely to undergo high-complexity laparoscopic procedures (10.4%, 15.4%, and 19.8%, respectively; p = 0.015) and had younger median age 49 years, 51 years, and 46 years, respectively; p = 0.035. Nineteen (2.3%) patients experienced pulmonary complications — symptomatic atelectasis (n = 9), pneumonia (n = 5), acute respiratory failure (n = 2), hypoxemia (n = 1), pneumomediastinum (n = 1), and pneumothorax (n = 2). The rate of pulmonary complications was 2.1% (12 of 564 patients) in never smokers, 4.5% (7 of 156 patients) in past smokers, and zero in current smokers.

Conclusion

In this cohort, smoking history did not appear to impact postoperative pulmonary and upper respiratory complications. In smokers scheduled for operative procedures, laparoscopy should be considered when feasible.     

A randomized trial of chewing gum to prevent postoperative ileus after laparotomy for benign gynecologic surgery

Objective

To assess whether chewing gum prevents postoperative ileus after laparotomy for benign gynecologic surgery.

Methods

A randomized study was conducted from December 1, 2010, to February 29, 2012. Patients scheduled to undergo laparotomy were randomly assigned to receive chewing gum or routine care after surgery. A chart review was performed to establish incidence of nausea and vomiting, use of antiemetics, cases of postoperative ileus (≥ 2 episodes of emesis of 100 mL or more, with abdominal distention and absence of bowel sounds), and time to discharge. Inpatient surveys recorded the time to specific events.

Results

A total of 109 patients were randomly assigned to receive chewing gum (n = 51) or routine postoperative care (n = 58). Fewer participants assigned to receive chewing gum than routine care experienced postoperative nausea (16 [31.4%] versus 29 [50.0%]; P = 0.049) and postoperative ileus (0 vs 5 [8.6%]; P = 0.032). There were no differences in the need for postoperative antiemetics, episodes of postoperative vomiting, readmissions, repeat surgeries, time to first hunger, time to toleration of clear liquids, time to regular diet, time to first flatus, or time to discharge.

Conclusion

Chewing gum after laparotomy for gynecologic surgery is safe and lowers the incidence of postoperative ileus and nausea.ClinicalTrials.gov:NCT01579175     

Endometrial leukemia inhibitory factor as a predictor of pregnancy after in vitro fertilization

Objective

To determine whether there is an association between endometrial expression of leukemia inhibitory factor (LIF) in the luteal phase of the menstrual cycle preceding in vitro fertilization (IVF) and treatment outcome.

Methods

Biopsy specimens from the endometria of 52 women in the luteal phase were immunostained against LIF. Embryo culture and transfer were done according to standard procedures.

Results

Clinical pregnancy occurred in 39% of the women following IVF, and strong endometrial immunohistochemical staining for LIF was associated with pregnancy (P = 0.01). The women with a strong LIF expression had a 6.4-fold higher chance of becoming pregnant than those with weaker intensities (P = 0.005).

Conclusion

Endometrial expression of LIF during the luteal phase can be used as a predictor of IVF success.     

Single-port versus conventional laparoscopic salpingectomy in tubal pregnancy: a comparison of surgical outcomes

Objective

To compare the surgical outcomes of single-port laparoscopic salpingectomy (SPLS) and conventional laparoscopic salpingectomy for the surgical treatment of tubal pregnancy.

Study design

From January to June 2009, patients with tubal pregnancy were assigned to two surgical groups: SPLS and conventional laparoscopic salpingectomy. Surgical outcomes, including operative time, postoperative haemoglobin drop, hospital stay and complications, were compared prospectively. For SPLS, a novel multichannel port was made using a wound retractor and a surgical glove.

Results

In total, 60 patients were enrolled in the study (30 in the SPLS group and 30 in the conventional group). All operations were completed successfully. No significant difference was observed between the two groups in terms of mean operative time (52.6 ± 16.1 min vs 46.8 ± 16.2 min; p = 0.174), mean difference between pre- and postoperative haemoglobin (1.7 ± 0.8 g/dl vs 1.8 ± 1.0 g/dl; p = 0.636), or mean postoperative hospital stay (2.4 ± 0.5 days vs 2.4 ± 0.9 days; p = 1.000). No complications were encountered in either group, and there was no conversion to conventional laparoscopy in the SPLS group.

Conclusion

SPLS has comparable surgical outcomes to conventional laparoscopic salpingectomy for the surgical treatment of tubal pregnancy in terms of operative time, hospital stay and complication rates. However, further studies are needed to evaluate the merits expected of single-port laparoscopic surgery, such as cosmetic advantage and decreased pain in patients.     

Single port transumbilical laparoscopic surgery for adnexal lesions: a single center experience in Korea

Objectives

The purpose of this study was to demonstrate the feasibility of single port transumbilical laparoscopic surgery (SPLS) for the treatment of adnexal lesions.

Methods

We have performed SPLS to treat adnexal lesions using a single three-channel port system with a wound retractor and surgical glove since October 2008. All patients who underwent SPLS for adnexal lesions between October 2008 and September 2009 were included in the study. We retrospectively reviewed their medical records and analyzed demographic data and surgical outcomes including age, medico-surgical illness, surgical indications, operative times and pathologic results.

Results

Eighty-six patients underwent SPLS for adnexal lesions. The median age of the patients was 31 years (range 14-78 years), the median body mass index was 21.0 kg/m² (range 16.7-32.2 kg/m²), and the median operation time was 64.5 min (range 21-176 min). The median blood loss was 10 ml (range 10-300 ml). The median length of postoperative hospital stay was 2 days (range 1-7 days). Endometriosis was the most frequently diagnosed etiology (34.9%). Other laparoscopic approaches were employed in two cases (2.3%). There were four cases (4.7%) with complications: three with pelvic infections and one with postoperative hemorrhage.

Conclusions

SPLS is a feasible approach for the treatment of adnexal lesions.     

Comparison of four perioperative misoprostol regimens for surgical termination of first-trimester pregnancy

Objective

To compare the outcomes of 4 different perioperative misoprostol regimens for surgical termination of first-trimester pregnancy.

Methods

Retrospective analysis of the records of 4000 women (4 cohorts of 1000 each) who underwent surgical termination of pregnancy. The 4 cohorts received: no misoprostol; 200 μg of oral misoprostol 30 minutes preoperatively; 200 μg of sublingual misoprostol 30 minutes preoperatively; or 200 μg of oral misoprostol 3 hours preoperatively plus 200 μg of vaginal misoprostol postoperatively. Adverse effects of the last regimen were surveyed in 1000 women.

Results

In the cohorts that received misoprostol, the difficulty of cervical dilatation was reduced (P < 0.001) compared with the cohort of women that did not receive misoprostol. The frequency with which women made postoperative contacts with the clinic was also reduced in the cohorts that received misoprostol (P < 0.05). Adverse effects were minimal.

Conclusions

This retrospective study showed an association between perioperative administration of misoprostol, reduced difficulty for operators, and reduced demand for postoperative care. The regimen associated with the greatest reduction in difficult cervical dilatations and postoperative consultations was 200 μg of oral misoprostol 3 hours preoperatively plus 200 μg of misoprostol vaginally at the end of the surgical procedure.     

Comparative study of dexamethasone and ondansetron for prophylaxis of postoperative nausea and vomiting in laparoscopic gynecologic surgery

Objective

To compare intravenous dexamethasone and ondansetron for the prophylaxis of postoperative nausea and vomiting (PONV), a main complaint that affects almost 40%-75% of patients undergoing laparoscopic gynecologic surgery.

Methods

In a prospective study, 93 women were divided into 3 groups receiving 4 mg of dexamethasone, 8 mg of dexamethasone, or 4 mg of ondansetron. PONV score was used for assessment during the first 24 hours after surgery.

Results

The incidence of PONV during the 24-hour postoperative period was highest in the ondansetron group (61%). In the first 3 hours, the incidence of PONV in the ondansetron group was also higher: 51.6% as compared with 22.6% and 36.6% in the dexamethasone 4 mg and 8 mg groups, respectively. The overall incidence of PONV was highest in the first 3 hours as compared with later time periods, and there was a linear trend in decreasing PONV among the groups (P = 0.017). In the dexamethasone 4 mg group, the request for a rescue antiemetic was significantly lower: 0% as compared with 6.7% and 16.1% in the dexamethasone 8 mg and ondansetron 4 mg groups, respectively.

Conclusion

Dexamethasone was found to be an efficacious and cost-effective drug for the prophylaxis of PONV.     

Frailty: an outcome predictor for elderly gynecologic oncology patients

Objectives

The objective of this pilot study was to determine if frailty predicts surgical complications among elderly women undergoing gynecologic oncology procedures.

Methods

A cohort of gynecologic oncology patients age ≥ 65, undergoing surgery between March and December 2011 was identified. Frailty was evaluated using a validated assessment tool. The primary outcome measure was 30 day postoperative complication rate.

Results

Forty women were approached for study entry and 37 (92%) enrolled. The mean age was 73 years (range 65-95). The majority of women had a malignancy and underwent a major abdominal surgical procedure. Twenty-one women (57%) were not frail, 10 (27%) were intermediately frail and 6 (16%) were frail. There was no difference in age or prevalence of medical comorbidities between groups. Frail women had a significantly higher BMI compared to intermediately frail and not frail women, (36.0, 31.5 and 26.1 kg/m², p = 0.02). The rate of 30-day surgical complications increased with frailty score and was 24%, versus 67% for women who were not frail as compared to the frail (p = 0.04).

Conclusions

Pre-operative frailty assessment is well accepted by gynecologic oncology patients and feasible in a clinic setting. Frail women had a higher BMI, indicating that low body weight is not a marker for frailty, and had a significantly higher rate of 30-day postoperative complications in this pilot study. Initial findings support the concept of measuring frailty as a possible predictor for postoperative morbidity that will allow for improved patient counseling and decision making.     

A cost analysis of postoperative management in endometrial cancer patients treated by robotics versus laparoscopic approach

Objective

The purpose of this study is to compare postoperative pain management and costs in endometrial cancer patients who had a robotic-assisted or laparoscopic-assisted hysterectomy.

Methods

This is a retrospective cohort study of all endometrial cancer patients from 9/2005 to 6/2010 who had a completed robotic-assisted or laparoscopic-assisted hysterectomy. All surgeries were performed by gynecologic oncologists on the da Vinci S surgical system. Demographic data, patient-recorded pain scores, pain-management interventions, and postoperative pain medication costs were compared. Data was analyzed using Student's t-tests and Pearson's χ² tests in SPSS.

Results

Two-hundred fifteen (101 robotic and 114 laparoscopic) patients met the inclusion criteria. There were no significant differences between the groups in age, BMI, clinical stage, comorbidities, lymph nodes retrieved, and the number of narcotic vs. non-narcotic drug interventions administered. Robotic patients had a lower number of initial drug interventions (21 vs. 52; P < .001) and total drug interventions (162 vs. 219; P < .001) than laparoscopic patients. Robotics had a lower initial pain score (2.1 vs. 3.0; P = .012). There was a 50% reduction in the pain medication cost on the day of surgery for robotic patients ($12.24 vs. $24.45; P < .01), and a 56% cost reduction for the rest of their length of stay ($3.63 vs. $8.17; P < .01).

Conclusion

Endometrial cancer patients who have robotic surgery experience less initial postoperative pain and have fewer drug interventions. The cost associated for their pain management represents a savings of greater than 50%. These factors demonstrate the value of robotic surgery in regard to postoperative pain management by delivering higher quality care at a lower cost.     

“Top hat” versus conventional loop electrosurgical excision procedure in women with a type 3 transformation zone

Objective

To compare the “top-hat” and conventional loop electrosurgical excision procedures (LEEP) performed in women with a type 3 transformation zone to assess the rate of endocervical margin involvement.

Methods

Women with a type 3 transformation zone randomly allocated into the conventional (n = 94) and top-hat LEEP (n = 86) groups were analyzed.

Results

The rate of endocervical margin involvement in the top-hat group was lower than that in the conventional group (32.6% vs 53.2%; RR 0.36; 95% CI, 0.19-0.68; P = 0.003). Among women with positive endocervical margins, women undergoing top-hat LEEP were less likely to have residual lesions compared with those in the conventional group (52.2% vs 84.1%, respectively, P = 0.04). There was no significant difference in the complication rate between the top-hat and conventional groups (7.0% vs 10.6%, respectively, P = 0.39).

Conclusion

Top-hat LEEP performed in women with a type 3 transformation zone reduces the risks of endocervical margin involvement and residual diseases compared with conventional LEEP, with no significant difference in perioperative complications.     

Effect of intra-abdominal instillation of lidocaine during minor laparoscopic procedures

Objective

To assess the effect of intraperitoneal instillation of lidocaine on postoperative pain after minor gynecological laparoscopic surgery.

Method

A prospective, double-blind, placebo-controlled clinical trial of 75 patients undergoing gynecological laparoscopy randomized to receive intraperitoneal instillation of either 120 mg of lidocaine (n = 60) or normal saline (n = 15) at the end of surgery. Postoperative pain was evaluated by Wong-Baker Faces Pain Rating Scale (WBFS) score at 15 minutes and at 1, 2, 4, 12, and 24 hours postoperatively.

Results

The WBFS score was lower for the lidocaine group than for the control group at 1, 2, and 4 hours after surgery (P = 0.023). There was no difference in WBFS scores between the 2 groups at 15 minutes (P = 0.46), 12 hours (P = 0.13), and 24 hours (P = 0.07) after surgery.

Conclusion

Intraperitoneal instillation of lidocaine was effective in reducing postoperative pain after minor gynecological laparoscopic procedures.     

Feasibility of laparoscopic extraperitoneal pelvic lymphadenectomy in gynecologic malignancies

Objective

The aim of this study is to evaluate the feasibility of laparoscopic extraperitoneal pelvic lymphadenectomy (LEPL) in gynecologic malignancies.

Methods

Twenty-nine women with cervical, ovarian or endometrial cancer underwent laparoscopic extraperitoneal pelvic lymphadenectomy between July 2008 and December 2010. The operating time, nodal yield, blood loss and complications were recorded.

Results

The number of patients with cervical, ovarian and endometrial carcinoma was 14, 3 and 12, respectively. The median age of patients was 48.9 ± 12.6 years. The median body mass index was 25.6 ± 4.8. Conversion to the transperitoneal laparoscopic approach was necessary in 6 patients for peritoneal tears causing CO₂ gas leakage. Among the remaining 23 patients, the median operating time for laparoscopic extraperitoneal pelvic lymphadenectomy was 69 min (range 50-126 min), and the median estimated blood loss was 20 ml (range 5-105 ml). The median total number of resected nodes was 26 (range 14-42), and complications related to the procedure were rare.

Conclusions

Laparoscopic extraperitoneal pelvic lymphadenectomy is a feasible and safe procedure. It can be used in gynecologic malignancies.     

Lymphatic ascites following pelvic and paraaortic lymphadenectomy procedures for gynecologic malignancies

Objective

Lymphatic ascites is an unusual complication in patients with cancer. In the gynecologic oncology patient population, the most common etiology is operative lymph node dissection. The purpose of this study was to explore the incidence, presenting symptoms, methods of diagnosis and treatment modalities utilized for lymphatic ascites in patients undergoing lymph node dissection for gynecologic cancers.

Methods

This observational study retrospectively reviewed the charts of patients who underwent lymphadenectomy as part of the surgical management for a gynecologic cancer. Patients that developed postoperative lymphatic ascites between January 2000 and December 2010 were included for analysis. Data extracted from the medical records included tumor pathology, number of harvested lymph nodes, postoperative course, method of diagnosis and treatment.

Results

From a total of 300 surgical staging procedures, 12 patients with lymphatic ascites were identified (4%). The most common reported symptom was leakage of clear fluid per vagina (7, 58%), followed by abdominal distension (4, 33%). The median interval from surgery to development of symptoms was 12.5 days (range 0-22 days). 5 patients had complete resolution of symptoms with dietary modifications alone while 7 patients required paracentesis. The median time from surgery to resolution of symptoms was 44 days (range 9-99).

Conclusion

Lymphatic ascites is an under recognized and infrequently reported postoperative complication. Although it usually resolves spontaneously or with conservative management without sequelae, this condition can significantly prolong postoperative recovery and cause patient discomfort. To our knowledge this is the largest group of patients undergoing gynecologic surgical staging procedures to be reviewed for the occurrence of lymphatic ascites.