Comparison of direct insertion of disposable and standard reusable laparoscopic trocars and previous pneumoperitoneum with Veress needle.

A randomized prospective study was conducted to evaluate the ease of use and safety of direct insertion of laparoscopic trocars. Comparison of previous pneumoperitoneum by Veress needle insertion with direct insertion of the reusable conventional laparoscopic trocar and direct insertion of the disposable shielded trocar revealed minor complication rates of 22, 6 and 0%, respectively. No major complications occurred in this series of 200 patients.     

A New Method for Laparoscopic Access to the Space of Retzius During Retropubic Cystourethropexy

Purpose

We assessed the feasibility of a new technique for laparoscopic dissection of the space of Retzius.

Materials and Methods

In 10 women 40 to 70 years old (median age 45) undergoing laparoscopic retropubic cystourethropexy for stress urinary incontinence hydrodissection was used to create a pneumo-subperitoneal space. A suction irrigator probe was inserted into a mid peritoneal incision created with a 5 mm. trocar above the symphysis pubis between the 2 umbilical ligaments. The subperitoneal space was developed and insufflated with carbon dioxide without incising the peritoneum.

Results

All procedures were completed laparoscopically without intraoperative or postoperative complications. Operative time for cystourethropexy ranged from 30 to 70 minutes (median 40). Estimated blood loss ranged from less than 50 to 300 ml. (median 100). Patients were discharged from the hospital within 24 to 48 hours. All patients reported satisfactory relief of symptoms at 3 to 6 months of followup.

Conclusions

The new technique is not difficult and may minimize tissue injury. Pneumosubperitoneal pressure provides clear exposure of the space of Retzius with minimal bleeding.     

Endometriosis in Adolescents

Background and Objectives:

Women with endometriosis often report onset of symptoms during adolescence; however, the diagnosis of endometriosis is often delayed. The aim of this study was to describe the experience of adolescents who underwent laparoscopy for pelvic pain and were diagnosed with endometriosis: specifically, the symptoms, time from onset of symptoms to correct diagnosis, number and type of medical professionals seen, diagnosis, treatment, and postoperative outcomes.

Methods:

We reviewed a series of 25 females ≤21 years of age with endometriosis diagnosed during laparoscopy for pelvic pain over an 8-year period. These patients were followed up for 1 year after surgery.

Results:

The mean age at the time of surgery was 17.2 (2.4) years (range, 10–21). The most common complaints were dysmenorrhea (64%), menorrhagia (44%), abnormal/irregular uterine bleeding (60%), ≥1 gastrointestinal symptoms (56%), and ≥1 genitourinary symptoms (52%). The mean time from the onset of symptoms until diagnosis was 22.8 (31.0) months (range, 1–132). The median number of physicians who evaluated their pain was 3 (2.3) (range, 1–12). The adolescents had stage I (68%), stage II (20%), and stage III (12%) disease. Atypical endometriosis lesions were most commonly observed during laparoscopy. At 1 year, 64% reported resolved pain, 16% improved pain, 12% continued pain, and 8% recurrent pain.

Conclusions:

Timely referral to a gynecologist experienced with laparoscopic diagnosis and treatment of endometriosis is critical to expedite care for adolescents with pelvic pain. Once the disease is diagnosed and treated, these patients have favorable outcomes with hormonal and nonhormonal therapy.     

Advanced Gynecologic Laparoscopy in a Fast-Track Ambulatory Surgery Center

Background/Objectives:

It has been shown that major gynecologic laparoscopy is safe in hospital ambulatory settings, but there is little data to suggest the same in freestanding ambulatory surgery centers. This study evaluates the safety and efficacy of advanced gynecologic laparoscopic surgery using a fast-track model in freestanding ambulatory surgery centers and discusses our institution protocols.

Methods:

Retrospective, multicenter review was conducted of major gynecologic surgeries from August 1^st 2010 to September 30^th 2011 in 3 surgical centers with one primary surgeon. All patients were treated for symptomatic uterine leiomyomas and/or endometriosis. Primary outcome measures were unplanned admissions and discharge within 23 hours.

Results:

One hundred and thirty-four patients underwent major laparoscopic gynecologic surgery with a total of 160 procedures: 77 stage IV endometriosis treatment including 7 disk excisions of endometriosis from the large bowel, 3 ureteroneocystostomies and 1 partial bladder resection, 38 myomectomies, and 34 hysterectomies including 12 modified radical hysterectomies. The overall unplanned admission rate was 4.5%. One hundred and thirty-one patients (97.7%) were discharged within 24 hours after surgery. Three patients (2.2%) were transferred to the hospital postoperatively: 1 patient for observation of postoperative anemia and 2 patients for postoperative fever. Three patients (2.2%) were admitted to the hospital after discharge: 1 patient for postoperative ileus, 1 patient for postoperative fever, and 1 patient with septic pelvic thrombophlebitis. These postoperative issues all resolved without complication, and all patients had an uneventful follow-up.

Conclusions:

With appropriate resources and an experienced surgeon, advanced laparoscopic surgery can be safely performed in a fast-track ambulatory surgery center with a high rate of discharge within 23 hours and low unplanned readmission rate.     

Infertility treatment: the viability of the laparoscopic view

Assisted reproductive technology (ART) and laparoscopy are not mutually exclusive, but coexisting and potentially complimentary treatments. For disease conditions contributing to infertility in addition to other concomitant or potential morbidity, laparoscopy represents a more comprehensive approach.     

Robotic-assisted laparoscopic partial bladder resection for the treatment of infiltrating endometriosis

This article reveals our surgical approach for treatment of a patient with severe pelvic and infiltrative bladder endometriosis with mucosal involvement using robotic-assisted laparoscopic excision and cystotomy repair. To our knowledge, this is the first case of total robotic-assisted laparoscopic partial bladder resection for the treatment of endometriosis. This article also discusses the pros and cons of robotic-assisted surgery and the current literature on infiltrative bladder endometriosis.     

New techniques in radical hysterectomy

PURPOSE OF REVIEW: To review the recent literature regarding modifications of abdominal radical hysterectomy as well as development of new approaches including laparoscopic, vaginal, and robotic radical hysterectomy. RECENT FINDINGS: Nerve-sparing radical hysterectomy technique allows for significant reduction in postoperative bladder morbidity. Radical vaginal hysterectomy with laparoscopic lymph node dissection is a well-recognized technique that offers excellent cure rates with absence of abdominal entry as well as reduced postoperative febrile and gastrointestinal morbidity. Total laparoscopic radical hysterectomy is a minimally invasive alternative to a traditional abdominal radical hysterectomy approach that yields comparable safety profile with a significant reduction in blood loss and hospital stay. Robotic surgery is becoming more widely accepted in the management of gynecologic cancers and larger series describing successful treatment of cervical cancer with robotic radical hysterectomy are soon to be published. SUMMARY: There are a number of approaches to performing radical hysterectomy. The feasibility and safety of these techniques have been well established. Preliminary oncologic outcome data are encouraging. The decision to utilize newer techniques depends on the patient and type of practice, as well as the surgeon's comfort level with laparoscopy, robotics, or vaginal surgery.     

Robotics and Gynecologic Oncology: Review of the Literature

The objectives of this article were to review the published scientific literature about robotics and its application to gynecologic oncology to date and to summarize findings of this advanced computerenhanced laparoscopic technique. Relevant sources were identified by a search of PUBMED from January 1950 to January 2009 using the key words Robot or Robotics and Cervical cancer, Endometrial cancer, Gynecologic oncology, and Ovarian cancer. Appropriate case reports, case series, retrospective studies, prospective trials, and review articles were selected. A total of 38 articles were identified on the subject, and 27 were included in the study. The data for gynecologic cancer show comparable results between robotic and laparoscopic surgery for estimated blood loss, operative time, length of hospital stay, and complications. Overall, there were more wound complications with the laparotomy approach compared with laparoscopy and robotic-assisted laparoscopy. There were more lymphocysts, lymphoceles, and lymphedema in the robotic-assisted laparoscopic group compared with the laparoscopy and laparotomy groups in patients with cervical cancer. Infectious and lung-related morbidity, postoperative ileus, and bleeding or clot formation were more commonly reported in the laparotomy group compared with the other 2 cohorts in patients with endometrial cancer. Computer-enhanced technology may enable more surgeons to convert laparotomies to laparoscopic surgery with its associated benefits. It seems that in the hands of experienced laparoscopic surgeons, final outcomes are the same with or without use of the robot. There is good evidence that robotic surgery facilitates laparoscopic surgery, with equivalent if not better operative time and comparable surgical outcomes, shorter hospital stay, and fewer major complications than with surgeries using the laparotomy approach.     

Proposal of a Formal Gynecologic Endoscopy Curriculum

As minimally invasive surgery becomes the standard of care in the United States and around the world, the formal training of endoscopic surgeons is an issue of growing concern. With the implementation of the American Association of Gynecologic Laparoscopists/Society of Reproductive Surgeons (AAGL/SRS)–sponsored fellowship training in gynecologic endoscopy and a growing number of hands-on courses, we have the challenge of credentialing and certifying future gynecologic endoscopists. The objective of this article is to propose and to illustrate a uniform standardized core curriculum for obstetrics and gynecology residents, fellows in AAGL/SRS-sponsored fellowship programs, and participants in postgraduate courses. Consisting of 3 discrete parts, this proposal addresses formal laparoscopic training for gynecologists, already implemented and available to general surgeons, and a novel proposition for core training in hysteroscopy. The curriculum is distributed in a quarterly system with specific educational objectives in each quarter. After quarters 1 and 2, an online examination is given; after quarter 3, participants are required to take and pass a hands-on examination at a specified testing facility; and at the end of quarter 4, participants must demonstrate leadership skills in the operating room and in a teaching capacity, and promote the principles of the AAGL.