Laparoscopic Ladd's procedure for intestinal malrotation: report of three cases.

Ladd's procedure for laparoscopic repair of malrotation has many advantages over conventional surgical techniques, such as earlier feeding and discharge. However, this procedure is still not commonly used in Taiwan. This report describes the results of treatment of intestinal malrotation in three patients using laparoscopic Ladd's procedure. The patients, aged 8 days, 17 days, and 3 years, underwent laparoscopic Ladd's procedure between July 1999 and September 2000. All three patients had symptoms of intermittent vomiting and were shown to have intestinal malrotation by upper gastrointestinal series study. The procedure was performed using three trocars of 5 mm diameter placed at the infraumbilical ring and the right and left lower quadrants. All procedures were completed laparoscopically. The operative times were 4.8, 3.6, and 3.5 hours, respectively. Feeding was started on postoperative Day 2 to 5, and the hospital stay was 6 to 11 days. Our results suggest that laparoscopic Ladd's procedure can be performed safely in pediatric patients. In addition, patients are expected to benefit from the smaller incision, earlier feeding, shorter hospital stay, and fewer complications compared with traditional Ladd's procedure.     

Laparoscopic hysterectomy in patients weighing 100 kg or more: a 7-year experience

Obesity is an increasingly prevalent condition in our society. The majority of hysterectomies are still being undertaken abdominally. Obese patients have a high rate of complications from abdominal surgery. Laparo-vaginal hysterectomy has a faster recovery than abdominal hysterectomy. If the uterine vessels are ligated laparoscopically at laparo-vaginal hysterectomy, there is a low conversion rate to abdominal hysterectomy. The aim of this study was to establish whether laparoscopic hysterectomy is a feasible alternative in obese patients. A 7-year audit of patients requiring a hysterectomy identified 27 women weighing 100 kg or more. All patients gave informed consent to an initial laparoscopic procedure, having been assessed as suitable for such, and then had a laparoscopic hysterectomy performed. Data regarding their operation was prospectively collected and retrospectively reviewed. All patients had successful laparoscopic hysterectomies with none requiring conversion to open operation, reoperation or readmission. There were no major complications. The postoperative stay was short (mean 2.4 days), but operation times were long (mean 175 min). Laparoscopic hysterectomy is a feasible alternative to abdominal hysterectomy in obese patients weighing 100 kg or more with low morbidity and fast recovery with short hospital stay.     

Laparoscopic and vaginal colpotomy for the excision of infiltrating cul-de-sac endometriosis

Palpable endometriotic nodules deep in the cul-de-sac and vagina represent the extension of intraperitoneal disease. Although such nodules used to be excised with vaginal colpotomy and by tracing the endometriosis to the peritoneum, the dissection of these lesions under laparoscopic visualization had aided in their removal. Of seven patients who were approached with a plan for combined laparoscopic and vaginal excision, five underwent the procedure. The last two required laparotomy due to bowel muscularis involvement.     

Laparoscopy in the diagnosis of polycystic ovarian syndrome

From March 1980 through June 1986, 93 patients clinically diagnosed as having polycystic ovarian syndrome (PCOS) were subject to laparoscopic examinations and laparoscopic ovarian biopsy. After statistical analysis of the results of the study, two improved diagnostic criteria for PCOS were suggested and compared with those proposed by Wortsman, et al and Stein-Leventhal. We think that the two improved diagnostic criteria are more suitable to the clinical practice and increase the diagnostic rate of PCOS to be 85% and 74% respectively. No operative complications such as intraabdominal hemorrhage, mechanical or electric injuries or infection was observed. The accuracy and criteria of laparoscopic diagnosis of PCOS are discussed.     

Laparoscopic management of adnexal masses: a gold standard?

PURPOSE OF REVIEW: To review recent literature on the laparoscopic management of adnexal masses, when this approach may be considered as a gold standard. RECENT FINDINGS: Cyst rupture was recently demonstrated to be a significant prognostic factor in stage I invasive epithelial carcinoma, and it was recommended to restrict the laparoscopic approach to patients with preoperative evidence that the cyst was benign. The laparoscopic approach is still highly controversial in masses suspicious at ultrasound. The limits of the laparoscopic approach are discussed reviewing recent literature and our experience. The laparoscopic management of adnexal masses appears to be safe in most hospitals even in developing countries. This approach is being used with increasing frequency in unusual indications such as newborns, children, adolescents and pregnant women. The learning curve for endoscopic surgery appears to be longer than expected. Many patients with benign adnexal masses, such as ovarian endometrioma, are still treated by laparotomy or with an inadequate endoscopic technique. Several studies have suggested that the stripping technique is a tissue-sparing procedure. SUMMARY: The laparoscopic puncture of malignant ovarian tumours confined to the ovaries is uncommon, and should be avoided whenever possible. The teaching of endoscopy is essential to promote adequate procedures performed according to the principles of microsurgery and to preserve postoperative ovarian physiology.     

Extended experience in the use of laparoscopic ultrasound to detect pelvic nodal metastasis in patients with cervical carcinoma

OBJECTIVE: To evaluate the use of laparoscopic ultrasound (USG) to detect pelvic nodal metastasis in patients with early stage cervical carcinoma. METHODS: Laparoscopic USG was used to search for pelvic lymph node metastasis in stage Ia2 to IIa cervical carcinoma patients before radical hysterectomy. Suspicious lymph nodes identified by laparoscopic USG were removed laparoscopically for pathological confirmation by frozen section. If nodal metastasis was diagnosed, radical hysterectomy would be cancelled but enlarged lymph nodes were removed preferably by laparoscopic approach before closing the abdomen. These patients were treated with radiotherapy after recovering from the surgery. By comparing the laparoscopic USG and pathological findings of lymph nodes removed with or without radical hysterectomy, diagnostic accuracy of laparoscopic USG was determined. RESULTS: Ninety-three patients were recruited and the final analysis included 90 patients. Laparoscopic USG found suspicious lymph nodes in 17 patients and nodal metastases were confirmed pathologically in 14 of them. Three patients with macroscopic and five patients with microscopic pelvic nodal metastases were missed by laparoscopic USG. The accuracy, sensitivity, specificity, positive and negative predictive value of laparoscopic USG in detecting pelvic lymph node metastasis were 87.8%, 63.6%, 95.6%, 82.4%, and 89%, respectively. Macroscopic metastatic nodes were successfully removed laparoscopically in 11 out of 14 patients and laparotomy was required for the other three patients. CONCLUSIONS: Laparoscopic USG can be performed with no major morbidity. This technique is sensitive in detecting macroscopic but not microscopic metastatic pelvic lymph nodes. Removal of macroscopic metastatic nodes identified via laparoscopic USG via laparoscopic approach could be accomplished in majority of patients.     

子宫内膜癌腹腔镜手术32例临床分析

目的探讨腹腔镜手术治疗子宫内膜癌的临床效果。方法回顾性分析北京大学人民医院2004年2月至2008年12月具有完整资料的子宫内膜癌腹腔镜手术32例患者,并与同期开腹手术32例比较,观察两组的围手术期指标和近期疗效。结果腹腔镜组术中出血量（345．31±276．60）ml,切除淋巴结数量（20．53±8．35）个,开腹组术中出血量（568．75±345．62）ml,切除淋巴结数量（30．41±11．17）个,差异均有统计学意义（P〈0．05）。两组手术时间比较,差异无统计学意义（P＝0．375）。腹腔镜组和开腹组肛门排气时间分别为（1．91±0．86）d和（2．91±1．67）d（P〈0．05）,平均住院时间分别为（17．22±6．19）d和（21．72±6．84）d（P=0．002）,差异均有统计学意义。腹腔镜组淋巴囊肿形成、切口愈合不良等术后并发症发生率明显低于开腹组（P〈0．05）。两组术后无瘤生存率（P=0．629）、总生存率（P=1．000）及复发率（P=0．629）差异均无统计学意义。结论腹腔镜手术术中出血量少、术后并发症少,近期疗效满意,是治疗早期子宫内膜癌较好的手术方式,但其远期治疗效果及长期预后需进一步研究。     

子宫内膜异位症不孕患者腹腔镜术后提高妊娠率方法及助孕时机选择

目的探讨子宫内膜异位症不孕患者腹腔镜术后提高妊娠率的有效方法及助孕时机的选择。方法选择浙江大学附属妇产科医院2006年1月至2008年1月331例子宫内膜异位症不孕患者为研究对象,根据其腹腔镜术后不同治疗方案分组:A组(82例)腹腔镜术后未用药物直接试孕者;B组(81例)腹腔镜术后试孕1年及以上未孕接受辅助生育技术(ART)者;C组(90例)腹腔镜术后应用促性腺激素释放激素激动剂(GnRH-a)辅助治疗3个月后直接试孕者;D组(78例)腹腔镜术后应用GnRH-a辅助治疗3个月后接受ART者。分析患者的临床病理资料,并追踪随访24个月。结果Ⅲ、Ⅳ期子宫内膜异位症不孕患者在术后2年内,妊娠率A组32.7%(17/52),B组58.0%(29/50),C组45.2%(28/62),D组59.6%(31/52),A组显著低于B和D组(P<0.01);A组与C组妊娠率比较,C组与B、D组的妊娠率比较,B组与D组的妊娠率比较,差异均无统计学意义(P>0.05)。结论Ⅲ、Ⅳ期子宫内膜异位症不孕患者腹腔镜术后采用ART治疗可以有效提高妊娠率;术后是否需要药物预治疗以及ART选择时机应根据患者年龄、不孕年限、病情程度等差异而制...     

Laparoscopic management of ovarian cysts

One hundred two women with ovarian cysts were managed laparoscopically over a 13-year period. Thirteen were treated with laparoscopic inspection followed by laparotomy, 6 with laparoscopic fine needle aspiration followed by laparotomy and 83 with laparoscopic fenestration and biopsy, with or without coagulation or removal of the cyst lining. Satisfactory results were noted in patients treated completely with laparoscopy. Only 1 of 56 functional, simple or paraovarian cysts recurred during the study period. Two of the 18 ovarian endometriomas treated with fenestration and coagulation or removal of the lining recurred, whereas 8 of 9 such lesions recurred when treated with fenestration alone. There were no surgical complications.     

FIGO-I期卵巢透明细胞癌患者预后分析

目的:探讨影响FIGO-I期卵巢透明细胞癌患者预后的因素,分析腹腔镜分期手术对I期卵巢透明细胞癌患者预后的影响.方法:回顾分析2000至2015年在北京协和医院妇产科住院治疗的103例I期卵巢透明细胞癌患者的临床病理资料,患者均经全面分期手术、术后辅助至少3个疗程铂类为基础的化疗方案.利用Kaplan-Meier模型和COX回归风险模型进行生存分析.结果:103例患者中,15例行腹腔镜分期手术(14.6%).肿瘤大小是影响腹腔镜分期手术抉择的唯一因素(P<0.05).中位随访45个月(9~194月)后,总5年生存率为90.4%,5年无复发生存率为86.8%.腹腔镜分期术患者的5年无复发生存率(73.3%)显著低于开腹分期术患者(89.5%)(P=0.004,HR 7.67,95%CI 1.94~30.65),与FIGO亚分期(Ia:100%vs Ic1~2:88.6%vs Ic3:31.3%)(P=0.009,HR 5.94,95%CI 1.56~22.62)同为I期卵巢透明细胞癌患者无复发生存的独立影响因素.由于总生存终点事件少,仅对FIGO亚分期(Ia:100%vs Ic1~2:92.5%vs Ic3:50.0%,P=0.001)、分期手术(腹腔镜分期术:86.7%vs开腹分期术:91.8%,P=0.061)进行单因素分析,腹腔镜分期手术未对患者总生存产生显著影响.结论:精确亚分期,包括收集腹水或腹腔冲洗液送检瘤细胞,注意避免肿瘤的医源性破裂外溢造成分期升级,对I期卵巢透明细胞癌患者预后具有重要价值.腹腔镜分期手术对于卵巢透明细胞癌的肿瘤安全性尚存争议,这一类患者施行此类手术需慎重.     

Single-port access laparoscopic surgery using a novel laparoscopic port (Octo-Port)

ObjectiveWe present our initial experience with single-port access (SPA) surgery using a novel laparoscopic port (Octo-Port).Materials, Methods, and ResultsIn a prospective study, SPA surgery was carried out on 11 patients with the Octo-Port from July 2009 to December 2009 by a single surgeon (T.-J. K.). The procedures carried out were hysterectomy (seven patients), ovarian cystectomy (two patients) and salpingo-oophorectomy (two patients). In 10 cases the procedure was successfully performed without the use of additional ports. In one case the SPA procedure failed and ancillary ports were required; this patient had anatomical variations that made use of the SPA technique difficult. All procedures were performed without complications. There were no perioperative port-related or surgical problems. The Octo-Port had certain advantages such as reducing the need for long laparoscopic instruments, reducing extracorporeal instrumental crowding, and providing better deflection of smoke compared to other SPA devices that used a wound retractor and a glove.ConclusionOur study demonstrated that the Octo-Port allows laparoscopic surgery to be performed safely and easily with a reduced number of ports.     

卵巢粘液性囊腺瘤患者不同手术治疗预后的对比研究

目的 :对比卵巢粘液性囊腺瘤 (囊瘤 )患者不同手术方法治疗的预后。方法 :回顾分析 81例卵巢粘液性囊腺瘤患者手术治疗后的随访情况 ,分析比较囊瘤切除和子宫附件切除术后及采用腹腔镜手术和剖腹手术后的复发率 ,也比较两种切除术中肿瘤破裂与否的癌变率和复发率。结果 :81例患者平均 4 2岁 (16～ 6 7岁 ) ,均随诊 2年以上 ,平均随诊时间 4 9个月 (2 4～ 12 0个月 )。癌变率为 1.2 % ,复发率为 8.6 %。囊瘤切除术 37例中 ,腹腔镜手术和剖腹手术途径的复发率分别为 16 .7%和 12 .5 % ,差异无显著性 ;切除术中肿瘤破裂与否的复发率分别为 16 .7%和 14 .3% ,差异亦无显著性 (P >0 .0 5 )。结论 :卵巢粘液性囊腺瘤切除术后的复发率显著高于子宫附件切除术。腹腔镜手术和剖腹术两种途径以及手术中囊腺瘤破裂与否对患者预后无显著影响     

Feasibility of laparoscopic extraperitoneal surgical staging for locally advanced cervical carcinoma in a gynecologic oncology fellowship training program

STUDY OBJECTIVE: Feasibility of laparoscopic extraperitoneal surgical staging for locally advanced cervical carcinoma in a gynecologic oncology fellowship training program. DESIGN: Retrospective analysis (II-2) of all patients who underwent laparoscopic extraperitoneal surgical staging at Women and Children's Hospital for locally advanced cervical cancer between June 2002 and June 2005. SETTING: Gynecologic oncology fellowship training program at a University-County Hospital PATIENTS: Thirty-two patients with clinical stage IIB-IVA cervical carcinoma were identified. INTERVENTIONS: Laparoscopic extraperitoneal surgical staging for clinical stage IIB-IVA cervical cancer. MEASUREMENTS AND MAIN RESULTS: A total of 32 cases of laparoscopic extraperitoneal surgical staging for locally advanced cervical cancer performed by fellows-in-training were identified. Fellows were first assistant surgeon in 10 cases, and operating surgeon in 22 cases. Each fellow was mentored an average of 5 cases as first assistant surgeon. As operating surgeon, all 22 fellow cases (100%) were successfully performed without conversion to laparotomy. Fellow mean operative time was 163 minutes. Fellow mean aortic nodal count was 14. Fellow mean blood loss was 42 mL. The mean hospital stay was 1.6 days. Overall, 2 patients (6.2%) experienced a complication from the procedure. Over one half (53%) of the patients reported a prior abdominal surgery. No lymphedema has been reported in patients who underwent laparoscopic extraperitoneal surgical staging with a median follow-up of 10 months. Surgical comorbidities such as hypertension, diabetes, and obesity were common in the study group. A steep surgical learning curve for the fellows was demonstrated by comparing mean operative times to academic year. Aortic nodal metastasis was detected in 25% of cases, and 14% were occult. CONCLUSIONS: It is feasible to teach laparoscopic extraperitoneal surgical staging to fellows-in-training. Our data suggest that by the end of training, fellows can become proficient with the procedure and are capable of surgical outcomes and complication rates comparable to reported literature.     

Laparoscopic ultrasonography in the management of ovarian cysts

BACKGROUND: The aim of the study was to determine the role of laparoscopic ultrasonography in the management of ovarian cysts extirpated by means of endoscopic surgery. METHODS: Laparoscopic ultrasonography was used during endoscopic surgery in 14 consecutive patients with an adnexal mass. The diagnostic accuracies of transvaginal and laparoscopic ultrasonography were compared according to the final pathological diagnosis. Estimations of the exact location of the ovarian mass by means of laparoscopic visualization and laparoscopic ultrasonography were compared. The presence of residual tumor tissue after cyst extirpation was monitored with laparoscopic ultrasonography. RESULTS: Using laparoscopic ultrasound and transvaginal ultrasound the correct diagnosis was made in 12 of 14 (85.7%) and 9 of 14 (64.3%) patients, respectively (not significantly different). With laparoscopic visualization, the exact location of the ovarian tumor could be demonstrated in 57.1% (8/14) of the cases, while with laparoscopic ultrasonography precise visualization of the ovarian mass was achieved in all cases (not significantly different). Two patients were found to have residual tumor tissue in the ovary when laparoscopic ultrasonography was performed again after tumor extirpation. CONCLUSION: Laparoscopic ultrasonography seems to be useful in patients with an adnexal mass managed by endoscopic surgery, in terms of evaluating the internal characteristics and predicting the histological diagnosis of the ovarian cyst, deciding on the correct placement of the incision to prevent unnecessary trauma to the ovary, and evaluation of the ovary after cyst extirpation to expose any residual tumor tissue.     

Small bowel herniation through subumbilical port site following laparoscopic surgery at the time of reversal of anesthesia

Incisional hernias through laparoscopic trocar sites are unusual complications of laparoscopy. Two cases of small bowel herniation at subumbilical port site occurred at the time of withdrawal of the trocar sheath at the end of the laparoscopic procedure are reported. The herniations were precipitated by the coughing movements of the patients as a result of too early reversal of the general anesthesia. Awareness of the complication, precaution at time of sheath withdrawal and a well-timed reversal of the general anesthesia are important in avoiding such a complication.     

Should we use visual entry techniques in patients with previous laparotomies?

Laparoscopic surgery has become the method of choice for treating an ever increasing number of gynaecological disorders that require surgery. However, primary port insertion is a potentially dangerous step especially in patients with previous laparotomies. The aim of this study is to identify whether visual entry technique has any advantage over the closed one in patients with previous laparotomies. This is a retrospective observational case control study of 2541 patients with previous laparotomies who underwent laparoscopic surgery from January 1992 to September 2003 at Vijaya Hospital, Kochi and from October 2003 to October 2015 at Department of Endoscopy, Paul’s Hospital, Kochi, India. The control group comprised of 1261 patients, operated between January 1992 and September 2003 at Vijaya Hospital, Kochi, in whom closed technique of abdominal access for primary port creation was used. The study group comprised of 1280 patients, operated between October 2003 and October 2015 at Department of Endoscopy, Paul’s Hospital, Kochi, in whom visual entry (EndoTIP) was used for primary port creation. Procedures included in both groups were total laparoscopic hysterectomy, laparoscopic myomectomy, laparoscopic ovarian cystectomy, laparoscopic conservative surgery, laparoscopic tubal reanastomosis, laparoscopic sacrocolpopexy, laparoscopic sacrocervicopexy, laparoscopic adhesiolysis and laparoscopic sterilisation. There was no evidence of intestinal or vascular injury during visual entry using a blunt EndoTIP cannula. There were three cases of bowel injury with the closed, blind entry technique using a sharp linear trocar in the control group. The p value (Chi-square test) is 0.04, which is statistically significant. Visual entry, as an approach to abdominal access in patients with previous laparotomies, wherein chances of encountering peritoneal and bowel adhesions are very high, is safer than the closed blind entry technique in preventing bowel injuries.     

A review of total laparoscopic hysterectomy: role, techniques and complications

PURPOSE OF REVIEW: The following review examines the current role of total laparoscopic hysterectomy, which is a hysterectomy completed entirely laparoscopically. Recent advances in equipment, surgical techniques and training have made total laparoscopic hysterectomy a well tolerated and efficient technique. It is increasingly being adopted around the world because of the benefits to patients and surgeons. This study discusses the role of total laparoscopic hysterectomy, provides some technical suggestions about how to perform a total laparoscopic hysterectomy and how to avoid possible complications. RECENT FINDINGS: Only a few surgeons performing total laparoscopic hysterectomy have published their techniques and results. The terminology and techniques for total laparoscopic hysterectomy used by different surgeons, such as energy sources, the use of uterine manipulators, vaginal tubes, the method for uterine artery ligation and method of vault closure, vary. This makes objective comparison of the literature, techniques and complication rates difficult. SUMMARY: As more surgeons become trained in advanced laparoscopic surgery, the role of total laparoscopic hysterectomy will increasingly take over indications for total abdominal hysterectomy. It remains important that surgeons share their experience and publish their techniques, results and complications. Advanced laparoscopic training and supervision are paramount before embarking on total laparoscopic hysterectomy, so that complications are minimized.     

Comparison between personal learning curves for abdominal and laparoscopic hysterectomy

BACKGROUND: To compare personal learning curves for abdominal and laparoscopic hysterectomy. METHODS: The first 200 patients scheduled for abdominal hysterectomy and the first 200 patients scheduled for laparoscopic hysterectomy by a single operator were compared using learning curves according to operation time, operative blood loss, and occurrence of complications. RESULTS: Learning curves for both types of hysterectomy were rather similiar, but the learning of the laparoscopic procedure seemed to be quicker. With increasing experience the operating time decreased by 25% in abdominal and by 41% in laparoscopic hysterectomies. The mean operating time in abdominal hysterectomy was 74 min and 70 min in laparoscopic hysterectomy. Operative blood loss decreased by 50% and 44%, respectively. The mean operative blood loss was smaller (203 vs 295 ml, p<0.0001) in laparoscopic hysterectomy. Increased experience had no effect on complication rates in abdominal hysterectomies, but a decrease of 44% was seen in laparoscopic hysterectomies (p<0.05). The overall complication rate (26% vs 22%) were similar for the two techniques, and only a few patients (1.5% vs 1%) had major (bladder or ureteric) complications. CONCLUSIONS: A trained gynecologist can learn the laparoscopic technique for hysterectomy at least as quickly as the abdominal technique.     

Laparoscopic lymphadenectomy as treatment of endometrial cancer

AIM: This study compares the effects of laparoscopic lymphadenectomy versus those of abdominal lymphadenectomy in patients with endometrial cancer. METHODS: A prospective randomized study was performed among 80 patients randomly assigned to laparoscopic lymphadenectomy and to abdominal lymphadenectomy in the treatment of endometrial cancer. Clinical outcomes and complications were compared for 1 year of follow-up. RESULTS: Forty patients were assigned to laparoscopic lymphadenectomy and 40 patients to abdominal lymphadenectomy. The laparoscopic approach was associated with a longer operative time (234.1 min vs 137.3 min) but was less painful (VAS 5.3 vs 7.9; P<0.000) and resulted in a shorter hospital stay (4.4+/-1 vs 7.9+/-1.2 days; P<0.000). At 6 weeks the quality of life was better in patients who had laparoscopic lymphadenectomy (SF-12). CONCLUSION: Laparoscopic lymphadenectomy was associated with a significantly lower rate of major and minor postoperative complications and a better short term quality of life.     

The role of laparoscopic lymphadenectomy in the management of cervical carcinoma.

Laparoscopic lymphadenectomy was performed on 18 patients with invasive carcinoma of the cervix prior to definitive radiation therapy and/or radical hysterectomy. Ten patients underwent pelvic and para-aortic lymphadenectomies prior to planned radiotherapy. Two of these patients had grossly positive pelvic nodes, and one had a microscopically positive para-aortic node. Eight patients with early disease were considered candidates for radical hysterectomy and underwent laparoscopic lymphadenectomy. Three of these patients were found to have positive pelvic lymph nodes and the hysterectomy was abandoned. Five patients underwent radical hysterectomies immediately following their laparoscopic procedures. The average number of lymph nodes removed laparoscopically in these patients was 31.4; the average number of additional lymph nodes resected at laparotomy with the radical hysterectomy was 2.8. A single microscopically positive parametrial lymph node was found on permanent section in 1 patient with radical hysterectomy. No significant complications were associated with the laparoscopic lymphadenectomies. Nine of the 13 patients who underwent laparoscopic procedures only were discharged on Postoperative Day 1. The ability to perform pelvic and para-aortic lymphadenectomy allows for complete surgical staging of carcinoma of the cervix laparoscopically.