Gynaecological laparoscopic surgery for benign conditions: do women care about incisions?

Where are we going with sentinel nodes mapping in ovarian cancer?

Lymph node involvement is a major predictive indicator in early-stage epithelial ovarian cancer (EOC). There is presently no effective way to determine lymph node involvement other than surgical staging. As a result, traditional ovarian cancer surgery still includes pelvic and paraaortic lymphadenectomy. However, it might be linked to higher blood loss, lengthier operations, and longer hospital stays. The creation of a technique for accurately predicting nodal status without significant lymphadenectomy is thus the subject of ongoing research. Sentinel lymph nodes (SLN) mapping is a routine procedure in oncological surgery and has been proven to be effective and safe in cervical, vulvar, and uterine cancer. On the other hand, SLN mapping is not yet widely accepted and recognized in EOC. A thorough search of the literature was conducted between January 1995 to March 2022, using PubMed and Embase. This review included studies on lymphatic outflow of the ovaries and the sentinel lymph node method. A total of 13 studies involving 212 patients who underwent sentinel lymph node mapping for ovaries were included. Both open and laparoscopic approach are used. The most popular injection site is the ovarian ligaments, and a variety of agents are utilized, although the main markers were, technetium-99m radiocolloid (Tc-99m) or indocyanine green, either alone or in combination. Overall detection rate for SLN in ovaries is 84.5% (interquartile range: 27-100%). We suggest a standardized method for sentinel lymph node mapping in ovarian cancer. The detection rates, characterization and true positive rates of the approach in investigations support further study. The use of ultra-staging is essential for lower-volume metastasis and reproducibility. To ascertain the clinical utility of sentinel node in early ovarian cancer, larger collaborative prospective clinical trials are necessary.

Recent advances in minimally invasive surgery for gynecologic indications

Recently, an increasing interest in less invasive surgery has led to the advent of laparoendoscopic single-site surgery (LESS) and natural orifice transluminal endoscopic surgery (NOTES). LESS and NOTES could be technically challenging, but available literature has demonstrated the feasibility and safety of LESS for benign gynecologic diseases. However, the evidence is not strong enough to recommend the use of LESS over that of conventional multiport laparoscopic surgery (MLS). As per the results of the most recently published meta-analysis, the majority of surgical outcomes are equivalent between LESS and MLS, except for the longer operative time in LESS for both adnexal surgery and hysterectomy. Although an increasing number of studies have reported on robotic LESS, NOTES, and LESS for gynecologic malignancy, definite conclusions have not been drawn owing to the lack of sufficient information.

Per-oral endoscopic salpingo-oophorectomy (POESY) in humans: a prospective clinical feasibility study

BACKGROUND AND AIMS

Natural orifice translumenal endoscopic surgery (NOTES) procedure describes a surgical approach using natural orifices. We describe a prospective non-comparative clinical study on transgastric salpingo-oophorectomy in humans.

METHODS

Patients with indication for salpingo-oophorectomy were offered the transgastric approach. This paper presents the data of the first 6 patients, in whom the procedure was performed. After gastroscopic incision in the anterior corpus wall we advanced the flexible gastroscope into the abdominal cavity. With the help of a transvaginally introduced 10 mm trocar and, if the uterus was present, an intrauterine manipulator, the salpingo-oophorectomy was performed. The colpotomy was dilated and the specimens were extracted in a bag. The gastrotomy was closed with an over-the-scope-clip and the colpotomy with a running suture.

RESULTS

The planned salpingo-oophorectomy was performed successfully in all patients. All patients recovered quickly and were discharged between the third and fifth day. In one patient a gastric bleeding was seen on the first postoperative day. The bleeding was clipped gastroscopically, all other follow ups were uneventful.

CONCLUSION

Our study demonstrates the feasibility of the transgastric access to the pelvis. The gastroscope provided excellent optical control and good tissue preparation. Therefore, we conclude that pure NOTES procedures using the transgastric access to the adnexa are feasible. An increasing role of transgastric procedures for diseases in the pelvic region can be expected in particular if new endoscopic platforms with better means of instrumentation and tissue management become available.

Laparoendoscopic single-site surgery versus conventional laparoscopy for hysterectomy: a systematic review and meta-analysis

Purpose

To assess the safety and effectiveness of LESS compared to conventional hysterectomy.

Methods

The systematic review and meta-analysis was performed according to the MOOSE guideline, and quality of evidence was assessed using GRADE. Different databases were searched up to 4th of August 2016. Randomized controlled trials and cohort studies comparing LESS to the conventional laparoscopic hysterectomy were considered for inclusion.

Results

Of the 668 unique articles, 23 were found relevant. We investigated safety by analyzing the complication rate and found no significant differences between both groups [OR 0.94 (0.61, 1.44), I² = 19%]. We assessed effectiveness by analyzing conversion risk, postoperative pain, and patient satisfaction. For conversion rates to laparotomy, no differences were identified [OR 1.60 (0.40, 6.38), I² = 45%]. In 3.5% of the cases in the LESS group, an additional port was needed during LESS. For postoperative pain scores and patient satisfaction, some of the included studies reported favorable results for LESS, but the clinical relevance was non-significant. Concerning secondary outcomes, only a difference in operative time was found in favor of the conventional group [MD 11.3 min (5.45–17.17), I² = 89%]. The quality of evidence for our primary outcomes was low or very low due to the study designs and lack of power for the specified outcomes. Therefore, caution is urged when interpreting the results.

Conclusion

The single-port technique for benign hysterectomy is feasible, safe, and equally effective compared to the conventional technique. No clinically relevant advantages were identified, and as no data on cost effectiveness are available, there are currently not enough valid arguments to broadly implement LESS for hysterectomy.

Electronic supplementary material

The online version of this article (doi:10.1007/s00404-017-4323-y) contains supplementary material, which is available to authorized users.