Hand-Assisted Approach to Laparoscopic Myomectomy and Hysterectomy

Effectiveness of a lower-abdominal incision in an extremely underweight patient with thin skin who underwent laparotomy during an upper abdominal surgery: A case report

INTRODUCTION

Although laparoscopic surgery is often difficult in patients with obesity, very few studies have investigated its difficulty in extremely underweight patients.

PRESENTATION OF CASE

We present the case of a 44-year-old nulliparous woman with an extremely low body weight who underwent laparoscopic adnexal surgery. She had undergone laparotomy for partial hepatectomy and was referred to our hospital 6 months later for an ovarian tumor. She weighed 25.5 kg and had a body mass index of 10.6 kg/m2. Abdominal magnetic resonance imaging revealed a relatively large rectus abdominis and a dilated bowel. An umbilical approach was considered dangerous because of the existing surgical scar. Thus, a small incision was made in the lower abdomen, and the first trocar was inserted under direct view. Laparoscopic resection of the right adnexa was performed; however, the operative time was longer than expected (96 min) because the dilated intestinal tract obstructed our view and the lower abdominal mini-incision approach with the EZ access device was used.

DISCUSSION

Underweight patients are reportedly at an increased risk of subcutaneous emphysema and initial trocar puncture injuries. We avoided these by approaching through a small, lower abdominal incision. We considered the unexpectedly rapid and deep trocar entry to be dangerous and expected a hand-assisted approach to be safer.

CONCLUSION

Our findings indicate that considerably difficulties are encountered during a laparoscopic surgery in extremely underweight patients with a history of laparotomy; thus, special care should be taken during such surgeries.

Uterine Morcellation for Presumed Leiomyomas: ACOG Committee Opinion, Number 822

ABSTRACT

Morcellation is a surgical technique used to reduce the size of the uterus or myomas by creating smaller pieces to allow the tissue to be removed through small incisions or with laparoscopic instruments. Open (uncontained) morcellation of the uterus and myomas has been scrutinized because of the possible spread of an unsuspected leiomyosarcoma while using a power morcellator during a hysterectomy or myomectomy for presumed symptomatic uterine leiomyomas. Before considering morcellation of the uterus, a woman should be evaluated to determine if she is at increased risk of malignancy of the uterine corpus. Morcellation of a malignancy is contraindicated and women should be evaluated preoperatively to identify malignancy. However, leiomyosarcoma cannot be reliably diagnosed preoperatively; thus, there is a risk that a woman with a presumed leiomyoma may have a malignancy that may be spread through morcellation, leading to a potentially worsened prognosis. Although an abdominal hysterectomy or myomectomy may reduce the chance of spreading cancer cells in women with undiagnosed leiomyosarcoma, it is associated with increased morbidity when compared with minimally invasive approaches. The obstetrician-gynecologist and patient should engage in shared decision making, including informed consent, explaining the risks and benefits of each approach to surgery for presumed leiomyomas, the risks and benefits of morcellation, and alternatives to morcellation.

A comparison of three approaches for laparoscopic single-site (LESS) myomectomy: conventional, robotic, and hand assisted

The objective of this study is to determine the feasibility and explore criteria for patient selection for three methods of LESS myomectomy: conventional (C-LESS), robotic-assisted (RA-LESS), and hand-assisted (HA-LESS). This was a retrospective case review of 72 patients with uterine myomas, conducted in a large academic tertiary care hospital between March 1, 2015, and November 7, 2018. LESS myomectomy via conventional, robotic, and hand-assisted routes. 43 patients underwent C-LESS, 15 underwent RA-LESS, and 14 underwent HA-LESS, with no conversions to open abdominal myomectomy. The operative outcomes were compared across the three approaches. The HA-LESS group had the largest mean number (HA: 6.9; C: 3.7; RA: 2.9, P=0.001), diameter (HA: 11.3 cm; C: 9.3 cm; RA: 7.1 cm, P=0.035), and weight (HA: 850.1 g; C: 320.7 g; RA: 181.1 g, P=0.003) of myomas removed per patient. The use of this method was also found to have a direct correlation with estimated preoperative uterine size (HA: 20.1 weeks; C: 16.2 weeks; RA: 12.0 weeks, P=0.001. Operative time and postoperative stay were found to be not statistically different across groups. We conclude that all three types of LESS myomectomy are feasible with comparable surgical outcomes. Most importantly, our findings indicate that hand assistance can be combined with C-LESS myomectomy for large or multi-fibroid uterus without compromising operating time or patient recovery. Notably, we found that uterine size could be a useful tool for the determination of the surgical approach.

Performance of a Haptic Feedback Grasper in Laparoscopic Surgery: A Randomized Pilot Comparison With Conventional Graspers in a Porcine Model

Background. Compared with open surgery, minimally invasive surgery is limited by reduced sensation of tissue properties. A laparoscopic grasper with integrated haptic feedback technology that improves the ability to sense tissue properties might provide a solution. The force reflecting operation instrument (FROI) is a new laparoscopic grasper, designed to provide information about the interaction forces between the instrument and tissue through resistance in the handle. This pilot study aimed to assess the functionality of the FROI compared with a conventional grasper in an in vivo setting. Methods. In this randomized trial, we used a standard laparoscopic surgical setup to perform laparoscopic surgery in pigs. In all, 11 surgeons performed colorectal, gynecological, or urological procedures, once with the FROI and once with a conventional grasper. Participants were asked to complete the NASA Task Load Index Rating Scale and rate 5 specific features for both graspers. To capture opinions on the overall functionality of the FROI, participants were asked to answer 8 open questions. Results. The surgeons reported that the use of the FROI significantly improved tissue consistency perception, arterial pulse detection, and force control compared with the conventional grasper. No significant differences were found in surgeons' muscular strain or operative time. The most emphasized topics in the open questions were improved soft-tissue handling and importance for complex procedures. Conclusion. Through this first in vivo analysis of the functionality of the FROI, a multispecialty group of laparoscopic surgeons confirmed the added value of haptic feedback technology in a live surgical setting.

Perioperative Outcomes of Myomectomy for Extreme Myoma Burden: Comparison of Surgical Approaches

STUDY OBJECTIVE

To describe the perioperative outcomes of various modes of myomectomy (abdominal [AM], laparoscopic [LM], or robotic [RM]) in cases of extreme myoma burden.

DESIGN

Retrospective cohort study (Canadian Task Force classification II-2).

SETTING

A tertiary academic center in Boston, Massachusetts.

PATIENTS

All women who underwent an AM, LM, or RM for extreme myoma burden, defined as representing the upper quartile for specimen weight (≥434.6 g) or myoma count (≥7 myomas), between 2009 and 2016.

INTERVENTIONS

Baseline demographics and perioperative outcomes were collected from review of medical records, including estimated blood loss, operative time, length of stay, and complications. Univariate linear and logistic regression analyses were conducted.

MEASUREMENTS AND MAIN RESULTS

During the study period 659 women underwent myomectomy for extreme myoma burden; 47.2% of cases were AM, 28.1% LM, and 24.7% RM. Overall myoma burden differed across the 3 routes and was greatest in the AM group (mean weight: 696.2 ± 784.5 g for AM vs 586.6 ± 426.1 g for LM and 586.6 ± 426.1 g for RM; mean number: 16.8 ± 15.0 for AM vs 7.2 ± 7.0 for LM and 6.7 ± 4.7 for RM; p <.001 for both). The 3 routes differed in operative time and length of stay, with RM having the longest operative time (mean, 239.7 minutes; p <.001) and AM the longest length of stay (mean, 2.2 ± .9 days; p <.001). Other perioperative outcomes were similar across the surgical approaches. Increasing myoma burden was associated with an increased risk of perioperative complications for all surgical approaches, with a threshold of 13 myomas associated with an almost 2-fold higher risk of perioperative complications (odds ratio, 1.77; 95% confidence interval, 1.17-2.70; p = .009). Cumulative incidence of perioperative complications with increasing specimen weight was greater in the RM cases as compared with AM (p = .002) or LM (p = .020), whereas the cumulative incidence of perioperative complications with increasing myoma count was lowest with AM compared with LM (p <.001) or RM (p <.001).

CONCLUSION

Myomectomy for extreme myomas is feasible using an abdominal, laparoscopic, or robotic approach. Increased myoma burden is associated with an increased risk of perioperative complications. A threshold of 13 myomas was associated with an almost 2-fold higher risk of perioperative complications for all modes. Perioperative complication outcomes were more favorable in AM or LM over RM with increased myoma weight and AM over LM or RM with increased myoma number.

The effects of laparoscopic graspers with enhanced haptic feedback on applied forces: a randomized comparison with conventional graspers

Background

Haptic feedback, which enables surgeons to perceive information on interaction forces between instrument and tissue, is deficient in laparoscopic surgery. This information, however, is essential for accurate tissue manipulation and recognition of tissue consistencies. To this end, a laparoscopic grasper with enhanced haptic feedback has been developed: the force reflecting operation instrument (FROI). This study tested the effects of enhanced haptic feedback on force control, tissue consistency interpretation, and the associated surgeons’ level of confidence through a randomized controlled crossover experiment.

Methods

A randomized three-period crossover trial was conducted, in which seven surgical residents and 13 medical students participated. The setup involved a box trainer in which slices of porcine organs (lung, small intestine, or liver) were presented. Participants performed three series of blinded palpation tasks involving three different graspers: the conventional grasper, the FROI with enhanced haptic feedback activated, and the FROI with enhanced haptic feedback deactivated. In each series, nine pairs of organ tissues were palpated to compare consistencies. The orders of presenting both instruments and tissues were randomized.

Results

The force applied during tissue palpation significantly decreased, by a mean factor of 3.1 with enhanced haptic feedback. Tissue consistency interpretation was significantly improved with more correct assessments and participants answered with significantly more confidence when enhanced haptic feedback was available.

Conclusion

The availability of enhanced haptic feedback enabled participants to operate with significantly reduced interaction force between instrument and tissues. This observation is expected to have multiple important clinical implications, such as less tissue damage, fewer complications, shorter operation times, and improved ergonomics.

The Utility of Hand-Assisted Laparoscopic Surgery (HALS) in Giant Pelvic Masses

The purpose of this study was to report the outcomes of a series of patients who underwent hand-assisted laparoscopy surgery for benign giant pelvic masses, including ovarian cysts and uterine myomas. We reviewed the records of all patients who underwent laparoscopic or hand-assisted laparoscopy surgery for a variety of benign gynecological conditions. Demographic, clinical, pathologic, and follow-up information was analyzed. Twelve patients have undergone hand-assisted laparoscopy for giant pelvic mass, including four hand-assisted laparoscopic myomectomy, four oophorocystectomy, and four salpingo-oophorectomy. The median age was 35.5 (19-55). The median BMI was 22.05 (19.8-26.7 kg/m(2)). The median diameter of adnexal mass was 21 (17-24 cm). The median diameter of uterine myoma was 18.5 (16-19 cm). The median length of hand-assisted (HA) incision was 5 cm (2-6 cm). The median operation time was 100 min (70 to 180 minutes), and median estimated blood loss was 60 mL (30 to 800 mL). The median length of stay was 3 days (3-5 days). There was no case of intraoperative and postoperative complications. Hand-assisted laparoscopic surgery is safe and feasible in the management of patients with benign giant pelvic masses. Additional studies are needed to further investigate potential advantages and outcomes of the technique.

Laparoscopic Hysterectomy for Uterine Fibroids: Is it Safe?

As more complex cases and larger uterine specimens are able to be managed with minimally invasive surgery, the limitations of tissue retrieval with these methods are of increasing concern. Risks of morcellator-related injury, tissue dissemination, or fragmentation must be weighed against increased morbidity of abdominal approach to hysterectomy. In an effort to mitigate the risks of tissue morcellation, containment system use must be considered when fragmenting a specimen, either with power morcellation or a manual technique via the vagina or minilaparotomy.