Laparoscopic port site metastases: Incidence, risk factors, and potential preventive measures

Laparoscopic Port-Site Metastasis From Prostate Cancer on 18F-Fluciclovine PET/CT

ABSTRACT

Laparoscopic port-site metastasis from prostate cancer is a rare complication after radical prostatectomy and pelvic lymph node dissection. We report a case of port-site metastasis from prostate cancer identified on 18F-fluciclovine PET/CT for a patient with evidence of biochemical recurrence. Final pathology after targeted ultrasound and biopsy of the mass in the right abdominal wall revealed prostatic adenocarcinoma.

Renal fossa recurrence with synchronous port site and appendicular metastases after laparoscopic nephrectomy: Role of metastases and abdominal wall en bloc resection

Isolated renal fossa recurrence and port site metastasis after laparoscopic nephrectomy are two different entities, and despite being rare, in selected cases would benefit from surgical resection. We report the case of a 61-year-old male with local renal fossa recurrence with synchronous metastasis involving the port site, the abdominal wall and the appendix, which was successfully treated with open surgical resection and is free of metastasis or recurrence. To conclude opportune treatment of similar cases, remain a safe and curative option, and should be considered after reviewing the case within a multidisciplinary team.

The Pathogenesis and Prevention of Port-Site Metastasis in Gynecologic Oncology

Port-site metastasis (PSM) is a specific and challenging complication of laparoscopic gynecologic oncologic procedures. Research has demonstrated that PSM is associated with significant morbidity and poor outcome. The exact pathogenesis of PSM in gynecologic patients is not clear. Several preventive measures of PSM have been addressed in the relevant literature, and novel approaches to prevent this uncommon complication keep emerging. In this review, we summarized the potential mechanisms of PSM and discuss the controversies and merits of proposed preventive measures of PSM in gynecologic oncology. We undertook a literature search using the Medline database to identify studies on the pathogenesis and prevention of laparoscopic PSM. Hypotheses of PSM pathogeneses center on the immune response, pneumoperitoneum, wound contamination, and surgical method. Cogent evidence of effective prevention of PSM after laparoscopic surgery is lacking. Traditional preventive actions such as irrigation and tumor manipulation should be taken individually. Insufflation of hyperthermic CO₂ and humidified CO₂ leads to a better outcome in patients with a malignant tumor who undergo a laparoscopic procedure compared with normal CO₂ pneumoperitoneum. Port-site resection shows no advantage in survival and results in more wound events. PSM prevention plays a crucial part in the overall care of patients with gynecologic malignancies who undergo laparoscopic procedures.

Trocar site recurrence after robotic partial nephrectomy to treat of renal cell carcinoma

Introduction:

Wound seeding during surgical excision of malignant tumor is known problem in the oncologic surgery. Trocar site recurrence (TSR) is well described in laparoscopic oncologic surgery. Little has been reported about TSR after robotic partial nephrectomy (RPN) performed for renal cell carcinoma (RCC). Here, we report on the incidence of TSR and demonstrate the presentation of this type of RCC recurrence.

Patients and Methods:

We reviewed prospectively collected data about patient who underwent RPN at our institute from September 2009 to March 2018. We reviewed the medical record of the patients who had the diagnosis of RCC on the final pathology. We identified the patient with TSR and demonstrated their presentation and treatment along with the outcome.

Results:

A total of 335 patients underwent RPN during the study period for renal mass. Two hundred and sixty-nine (80.3%) patients were found to have RCC on the final pathologic evaluation of their mass. We identified two patients (0.7% of all the RCC in the study) who developed TSR during an average follow-up period of 31 months (ranging from 18 to 72 months). The first recurrence appeared 18 months after the surgery. The second recurrence presented 72 months after RPN. Both cases underwent open surgical excision of the trocar site, in which the recurrence appeared.

Conclusion:

TSR is potential type of RCC recurrence after RPN, though it is rare and underreported. Special attention should be given to examine the trocar site during the surveillance follow-up of RCC treated with RPN. It can develop up to 72 months after the surgery.

Laparoscopic port-site metastasis as the manifestation of neuroendocrine prostate cancer: Case report and literature review

Introduction

The neuroendocrine differentiation in prostate cancer is a rare entity that may occur as de novo, or as a result of treatment with androgen deprivation. It is characterized by its rapid progression and poor prognosis, without elevation of the prostate specific antigen (PSA), which is why it is often diagnosed by biopsy of a site of metastasis; there are no established treatment regimens. In this case, metastasis was presented as implantation to a laparoscopic port. These implantations subsequent to laparoscopic procedures in prostate cancer are very rare, with an incidence between 0.09 and 0.7%. The exact pathogenesis of the tumor implantation at the insertion site is not clear, there are several theories.

Materials and methods

We describe the case of a 53-year-old patient with a diagnosis of prostate adenocarcinoma who underwent laparoscopic radical prostatectomy plus lymphadenectomy, staged as PT3BN0 (0/6) M0R1 Gleason 4 + 5. The patient never had negative PSA levels after the treatment, and presented elevation of the same, so radiotherapy was performed at a dose of 66 Gy plus antiandrogen deprivation therapy with leuprolide acetate for 30 months, with a decrease in PSA to 0.011 ng/ml, which remained stable. After 3 months of hormonal therapy, he presented with an umbilical mass on the scar of the laparoscopic port; ultrasound and computed tomography were performed, showing a solid mass dependent of the umbilical upper edge with a defect in the abdominal wall of 3 cm, as well as hepatic nodules suggestive of metastatic lesions and peritoneal implantations.

Results

A biopsy of the abdominal wall lesion was performed, documenting poorly differentiated carcinoma with an immune-profile consistent with neuroendocrine carcinoma; immunohistochemistry showed strong and diffuse positivity with cytokeratin cocktail and chromogranin. In conjunction with oncology, treatment with chemotherapy was decided. He received six cycles of cisplatin and etoposide, with progression of his disease and death seven months after diagnosis.

Conclusions

Prostate cancer with neuroendocrine differentiation is a rare entity, usually occurring in the castration resistance stage, with poor prognosis and survival of less than 1 year. It presents as clinical and radiological progression without elevation of the PSA. Although it is very rare, the possible causes include tumor implantation in laparoscopic ports and/or open surgery scars, so caution and certain precautions must be taken when performing radical prostatectomy. In case of suspecting a tumor with neuroendocrine differentiation, biopsy and immunohistochemistry studies should be performed in order to clarify the diagnosis and provide a multimodal treatment based on surgery, radiotherapy and chemotherapy.

Prostate cancer laparoscopic port site metastasis: A case report

INTRODUCTION

Laparoscopic port site metastases are a rare but clinically important cause of biochemically recurrent prostate adenocarcinoma. C-11 choline, among other prostate-specific positron emission tomography (PET) radiotracers, has improved radiologist confidence in these otherwise difficult-to-detect sites of recurrence.

PATIENT CONCERNS

A 62-year-old male presented with biochemically recurrent prostate adenocarcinoma after undergoing robotic-assisted radical prostatectomy 5 years earlier.

DIAGNOSIS

C-11 choline positron emission tomography/computed tomography (PET/CT) demonstrated a choline-avid soft tissue nodule associated with a laparoscopic port site in the right rectus abdominis muscle, with correlative findings on prior magnetic resonance imaging, and biopsy confirming a prostate adenocarcinoma metastasis.

INTERVENTIONS

The patient was initiated on chemohormonal therapy.

OUTCOMES

His prostate-specific antigen (PSA) became undetectable following chemohormonal therapy. A follow-up C-11 choline PET/CT demonstrated complete resolution of prior abnormal radiotracer activity in the right rectus abdominis muscle.

LESSONS

Port site metastases in prostate adenocarcinoma are rare; however, those who treat prostate cancer patients should be aware of this phenomenon as the number of minimally invasive oncologic procedures increase. C-11 choline PET, among other prostate-specific PET probes, has become an important tool in evaluating patients with biochemically recurrent prostate adenocarcinoma, identifying site-specific metastases in a majority of patients.

Progression to chronic kidney disease in patients undergoing nephrectomy for small renal masses: a price to pay for a therapeutic success?

Nephrectomy, which constitutes a gold-standard procedure for the treatment of renal-cell carcinoma (RCC), has been widely discussed in the past decade as a significant risk factor of the development of chronic kidney disease (CKD). RCC is the third most common genitourinary cancer in the United States, with an estimated more than 65,000 new cases and 14,970 deaths. The aim of this review was to precisely and comprehensively summarize the status of current knowledge in CKD risk factors after nephrectomy, the advantages of minimally invasive vs. radical nephrectomy, post-nephrectomy biomarkers of CKD, ways of post-operative CKD prevention and, therefore, better understand why various aspects of CKD after nephrectomy. The majority of current studies indicated a better long-term kidney function preservation in patients undergoing partial nephrectomy in comparison to those after radical nephrectomy. Furthermore, a nephron-sparing surgery should be a preferred first-line procedure among young patients with small renal masses. As partial nephrectomy is followed by a greater risk of adverse outcomes relative to radical nephrectomy, a potential survival benefit should always be considered especially in the elderly or patients with comorbidities.

Images: Port site recurrence on followup imaging after adrenalectomy for adrenocortical carcinoma - first indicator of carcinomatosis

Adrenocortical carcinoma (ACC) is a rare and aggressive malignancy of the adrenal cortex. Complete surgical resection is essential for localized tumours because ACC is highly resistant to chemotherapy and radiotherapy.1 Use of a laparoscopic approach for adrenalectomy in the setting of a confirmed or suspected ACC is controversial because it is unknown if laparoscopy provides equivalent oncological outcomes compared to an open approach.

Isolated prostate cancer soft tissue recurrence 10 years after radical prostatectomy

In advanced disease, prostate cancer is well known to invade locally as well as metastasise to distant locations. Metastases occur commonly in lymph nodes and bone but have also been known to involve certain visceral organs, particularly the lungs. Involvement of soft tissue by metastases is far less common, particularly in the context of cancer recurrence. We present the case of a male aged 68 years who presented with a rising prostate-specific antigen (PSA) 10 years after radical prostatectomy (RP). The PSA increased despite salvage radiotherapy and was ultimately found to be caused by a PSA secreting prostate cancer soft tissue mass in the suprapubic region. Surgical resection of the mass caused a sharp decline in the PSA to negligible levels. This case highlights the need for ongoing surveillance post-RP and the potential for prostate cancer recurrence in the soft tissue that is refractory to routine salvage radiotherapy.

Isolated port-site metastasis of hepatocellular carcinoma after laparoscopic liver resection

Port-site metastasis of hepatocellular carcinoma (HCC) is extremely rare, and only one case has been reported in the English-language literature. Contamination with malignant cells along the needle tract during percutaneous biopsy or radiofrequency ablation is a well-recognized cause of HCC recurrence. Here, we describe a case of port-site metastasis after laparoscopic liver resection of HCC. The patient, who had undergone laparoscopic partial resection of the left lateral segment of the liver 18 months earlier, was diagnosed with HCC. CT showed a nodule in the abdominal wall where the laparoscopic port had been inserted during resection. Local excision was performed, and histological examination revealed HCC consistent with recurrence after laparoscopic resection. The experience described in this report highlights the risk of port-site metastasis of HCC. Imaging for oncologic surveillance after laparoscopic resection must include all port sites.

Port-site metastasis as a primary complication following retroperitoneal laparoscopic radical resection of renal pelvis carcinoma or nephron-sparing surgery: A report of three cases and review of the literature

The present study reports the clinical data of two patients with renal pelvis carcinoma and one patient with renal carcinoma who developed port-site metastasis following retroperitoneal laparoscopic surgery. The current study aimed to identify the cause and prognosis of the occurrence of port-site metastasis subsequent to laparoscopic radical resection of renal pelvis carcinoma and nephron-sparing surgery. Post-operative pathology confirmed the presence of high-grade urothelial cell carcinoma in two patients and Fuhrman grade 3 renal clear cell carcinoma in one patient. Port-site metastasis was initially detected 1–7 months post-surgery. The two patients with renal pelvis carcinoma succumbed to the disease 2 and 4 months following the identification of the port-site metastasis, respectively, whereas the patient with renal carcinoma survived with no disease progression during the targeted therapy period. The occurrence of port-site metastasis may be attributed to systemic and local factors. Measures to reduce the development of this complication include strict compliance with the operating guidelines for tumor surgery, avoidance of air leakage at the port-site, complete removal of the specimen with an impermeable bag, irrigation of the laparoscopic instruments and incisional wound with povidone-iodine when necessary, and enhancement of the body's immunity. Close post-operative follow-up observation for signs of recurrence or metastasis is essential, and systemic chemotherapy may be required in patients with high-grade renal pelvis carcinoma and renal carcinoma in order to prolong life expectancy.

Isolated port-site metastasis after surgical staging for low-risk endometrioid endometrial cancer: A case report

Port-site metastases (PSMs) are well-known potential complications of laparoscopic surgery for gynaecologic malignancies. The present case study reports PSM following laparoscopic surgery for Stage IA Grade 1 endometrioid endometrial cancer (EEC). The recurrence developed within 7 months following primary surgery and required surgical excision followed by adjuvant chemo-radio therapy. After 9 months, the patient remains disease-free. PSMs are rare complications following laparoscopic surgery. Amongst the 23 cases of endometrial cancer PSMs reported so far, only 4 followed EEC Stage IA Grade 1-2. The present study reports a rare case of PSM after Stage IA Grade 1 EEC. The clinical and prognostic relevance of PSMs has not been identified so far; and it is not known whether PSMs represent a local recurrence or a systemic recurrence. Surgeons should be aware that even low-risk EEC may be followed by PSMs and should take steps to prevent these rare recurrences.

Port site metastasis in prostate cancer

Port-site metastasis of prostatic adenocarcinoma is rare and usually associated with poor prognosis. We report a case of a young man with a rising prostate-specific antigen (PSA) 4.5 years after robot-assisted laparoscopic prostatectomy (RALP) and extended pelvic lymphadenectomy (ePLND) for a Gleason 7 (4+3) prostate cancer (pT3b pN0 cM0). Choline positron emission tomography-computed tomography (PET-CT) demonstrated a PET positive subcutaneous recurrence in a previous trocar site accompanied by a PET positive ipsilateral inguinal lymph node. Excision of both lesions was performed, confirming the diagnosis of metastatic prostate cancer. The patient's PSA dropped significantly postoperatively enabling postponement of androgen deprivation treatment up to this date. The etiology of port-site metastasis is multifactorial, including patient and surgery related factors. Such metastases have been scarcely reported following ePLND with or without RALP. Certain surgical precautions can be made to prevent the occurrence. We summarize previously reported mechanisms of development and possible precautionary measures.

Port site metastases following laparoscopic liver resection for hepatocellular carcinoma

A laparoscopic approach is being used increasingly in specialist centres for the resection of hepatocellular carcinomas and compares favourably with the traditional open approach, in terms of perioperative morbidity and mortality as well as long-term survival. We present a case of port site recurrence in a patient who underwent a laparoscopic left lateral segmentectomy for a hepatocellular carcinoma diagnosed during investigation of symptomatic gallstones. Nearly three years following surgery, surveillance computed tomography demonstrated a suspicious lesion at the site of one of the laparoscopic ports. Further resection was carried out and the lesion was confirmed histologically to be an isolated recurrence of the primary hepatocellular carcinoma, involving peritoneum and adominal wall. This case demonstrates that it is possible to encounter port site metastasis following laparoscopic resection of primary liver tumours although the incidence is very rare.

Port site and peritoneal metastases after robot-assisted radical prostatectomy

INTRODUCTION

Port site metastasis after minimally invasive urologic surgery is a rare event despite the widespread utility of laparoscopic techniques in the management of urologic malignancies. Herein, we report a case of port site metastasis after robot-assisted radical prostatectomy.

PRESENTATION OF CASE

A currently 77-year-old male patient, who was diagnosed with cT2c, Gleason 7 (4+3) prostate adenocarcinoma in our clinic back in 2009, had undergone robot-assisted radical prostatectomy elsewhere. Histopathological examination revealed pT3a, Gleason 9 (4+5) disease. Lymph nodes were negative, however surgical margins were positive on the right side. PSA recurred after 9 months and maximal androgen blockade was initiated. Despite antiandrogenic manipulations, PSA reached 0.83ng/ml, 33 months postoperatively. Concurrently, we noticed a palpable anterior abdominal mass which demonstrated metabolic hyperactivity on PET scanning. Percutaneous biopsy of the lesion confirmed the presence of metastatic adenocarcinoma. PSA did not normalize after the complete excision of the metastatic focus. Repeated PET scan revealed multiple implants on the peritoneal surfaces of various organs.

DISCUSSION

Port site and peritoneal metastasis of prostate cancer after robot-assisted radical prostatectomy has not been reported so far. This peculiar dissemination pattern is most probably the result of tumor biology and perioperative factors.

CONCLUSION

Although encountered extremely rarely, surgeons should be aware of the possibility of port site and/or peritoneal metastases after minimally invasive radical prostatectomy.

Tumor seeding incidentally found two years after robotic-Assisted radical nephrectomy for papillary renal cell carcinoma. A case report and review of the literature

INTRODUCTION

Port-site metastasis or peritoneal spread after laparoscopic surgery for urological malignancies is a rare phenomenon accounting for 0.09% and 0.03% of the cases respectively.

PRESENTATION OF CASE

We present a case of tumor seeding in the omentum found in a female patient after previous transperitoneal robotic-assisted radical nephrectomy (RARN) for papillary renal cell carcinoma (RCC). Two years after the robotic operation, the patient was diagnosed with cervical clear cell carcinoma and underwent radical hysterectomy with lymphadenectomy and omentectomy. A neoplastic omental nodule was incidentally identified intraoperatively. Pathological characteristics and immunohistochemistry revealed features of papillary RCC. Two years after the hysterectomy, the patient is clinically cancer free, without any adjuvant therapy for her cervical cancer.

DISCUSSION

To the best of our knowledge, we report the first case of tumor seeding in the omentum following RARN for organ confined low grade papillary (T2aN0M0) RCC. No risk factors that could explain the tumor seeding were identified. The neoplastic cells had a low proliferative index (Ki-67<5%) and a decreased capability to metastasize.

CONCLUSION

Tumor seeding as a result of robotic assisted laparoscopic nephrectomy, although rare, might represent a novel way of tumor inoculation deprived of or with low malignant potential.

Single-session laparoscopic total urinary tract exenteration without repositioning for multifocal urothelial carcinoma in dialysis-dependent patients

OBJECTIVES

To report our experience of single-session, en bloc, laparoscopic total urinary tract exenteration in dialysis-dependent patients with multifocal urothelial carcinoma.

METHODS

From June 2005 to April 2008, 5 dialysis-dependent patients (4 women and 1 man) diagnosed with synchronous upper urinary tract and bladder urothelial carcinoma underwent single-session, en bloc, laparoscopic total urinary tract exenteration. Bilateral nephroureterectomy was facilitated by rotating the operating table with or without alternative inflation of the tourniquet cuffs on either side of the patient's back to allow adequate spontaneous bowel displacement by gravity, thereby avoiding the need to reposition the patient. After completing bilateral nephroureterectomy, we performed radical cystectomy with the patient in the Trendelenburg position. All specimens, including the 2 kidneys, ureters, and bladder, were collected in an endobag and were intended to be retrieved using the Pfannenstiel incision in male patients and the vaginal route in the female patients. The demographic and perioperative information were collected and analyzed.

RESULTS

All the laparoscopic procedures were completed successfully without major complications. Although 1 patient developed a minor complication owing to paralytic ileus, she recovered after conservative treatment. The continuity of all the urothelial epithelium was maintained intact throughout the procedure to avoid tumor spillage.

CONCLUSIONS

In our experience, laparoscopic total urinary tract exenteration is a technically feasible and safe alternative modality to the open counterpart to treat dialysis-dependent patients with end-stage renal disease with multifocal urothelial carcinoma for experienced surgeons with advanced laparoscopic skills. Furthermore, it can be performed successfully without the need for repositioning the patient, and this probably decreased the incidence of associated complication in the high-risk patients.

Laparoscopic resection of colorectal liver metastases: surgical and long-term oncologic outcome

OBJECTIVE

To analyze the immediate and long-term outcome after laparoscopic resection of colorectal liver metastases and difference between observed and predicted [Fong's and Basingstoke Predictive Index (BPI) scores] survivals.

BACKGROUND

: Laparoscopic liver resection has been reported safe and feasible and improves postoperative course. The oncologic outcomes after resection of colorectal metastases are poorly reported.

METHODS

Between August 1998 and January 2010, 122 patients underwent laparoscopic resection for colorectal liver metastases during 135 procedures at Rikshospitalet. Patients undergoing surgery between August 1998 and June 2009 were included in research analysis. The patients had median Fong's and BPI's scores of 2 (0-5) and 7 (0-23), respectively. Mainstream analysis of hospital data was done on intent-to-treat basis. Intraoperative incidents and postoperative complications were analyzed according to the Satava and Clavien-Dindo classifications. Median follow-up was 24 (0-100) months.

RESULTS

One hundred fifty-one liver resections were performed in 107 patients during 118 procedures: 117 nonanatomic and 34 anatomic liver resections. There were 5 conversions to laparotomy (4.2%). The resection margin was free of tumor tissue in 141 (93.4%) of 151 specimens, and the distance between the resection margin and tumor tissue was median 6 (0-40) mm. Intraoperative incidents occurred in 14 cases (11.9%), including 5 (4.2%), 8 (6.8%), and 1 (0.8%) cases of grades I, II, and III, respectively. Postoperative complications were observed in 16 cases (14.3%), including 2, 3, 7, 3, 0, and 1 cases of grades I, II, IIIa, IIIb, IV, and V, respectively. During follow-up, 21 patients received repeat liver resection of recurrences (11 by laparoscopy and 10 by laparotomy). The 5-year overall survival rates were 51% as laparoscopically completed cases and 47% as intent-to-treat. The observed actuarial survival values exceeded the values expected by Fong's and BPI's score, with 10.2% and 6.7% as laparoscopically completed cases and with 3.8% and 2.4% as intent-to-treat, respectively.

CONCLUSIONS

Laparoscopic resection is a favorable alternative to open liver resection for patients with colorectal liver metastases. The observed actuarial survival values after laparoscopic resection surpass the values expected by major scoring systems.

Pneumoperitoneum with carbon dioxide inhibits macrophage tumor necrosis factor-alpha secretion: source of transitional-cell carcinoma port-site metastasis, with prophylactic irrigation strategies to decrease laparoscopic oncologic risks

PURPOSE

Peritoneal macrophages play a critical role in maintaining local host resistance to infection and malignancy through the secretion of tumor necrosis factor-alpha (TNF-alpha). We hypothesized that attenuated TNF-alpha secretion, as a result of CO(2) pneumoperitoneum, could alter local immune surveillance, thereby contributing to the development of carcinomatosis and incisional metastasis. We further sought to determine if port-site metastasis could be prevented with prophylactic irrigants.

MATERIALS AND METHODS

C57BL/6 mice (n = 50) and the syngenic murine bladder tumor (MBT-2) cell line were used. Experiment 1: Mice were subjected to either CO(2) pneumoperitoneum at 6 mm Hg (n = 10) or a 3-cm midline incision (n = 10). Peritoneal macrophages (1 x 10(6)/animal) were collected and subjected to lipopolysaccharide challenge. TNF-alpha levels were quantified using the Quantikine Mouse TNF-alpha/TNFSF1A Immunoassay. Experiment 2: Peritoneal and port-site metastasis were evaluated 1 week after 1 x 10(6) MBT-2 cells/animal were spilled in an open group (n = 5) and through 5-mm trocars of a pneumoperitoneal group (n = 5). Experiment 3: 1 x 10(6) MBT-2 cells/animal were spilled intraperitoneally through 5-mm trocars of four groups (n = 20). Port sites in each group were then irrigated with either sterile water, mitomycin C (1.0 mg/mL), betadine (10%), or heparin (1000 U/mL). At 1 week, incisional sites were evaluated for gross and microscopic metastasis. In each experiment, Student t-test was used to quantify statistical differences.

RESULTS

Peritoneal macrophage TNF-alpha secretion was significantly inhibited in mice subjected to CO(2) pneumoperitoneum v control at 10 and 20 minutes (P = 0.015, P = 0.001, respectively). When 1 x 10(6) MBT-2 cells were spilled, a significantly higher average tumor burden developed in animals subjected to CO(2) pneumoperitoneum than in controls at 1 week (9.2 gm v 3.8 g, P = 0.002). All irrigants prevented the development of port-site metastasis, yet sterile water did so without toxic effect.

CONCLUSION

In a syngenic murine model, CO(2) pneumoperitoneum causes inhibition of peritoneal macrophage TNF-alpha secretion. Heavier intraperitoneal and incisional metastasis develops in C57BL/6 mice subjected to CO(2) pneumoperitoneum and a tumor challenge with 1 x 10(6) MBT-2 tumor cells compared with open controls. Inhibition of peritoneal macrophage TNF-alpha secretion may be considered an adverse event contributing to the development of transitional-cell carcinoma (TCC) port-site metastasis, especially if surgical oncologic principles are violated. Irrigating trocar sites and the peritoneal cavity with sterile water at the conclusion of laparoscopic nephroureterectomy and laparoscopic radical cystectomy may offer a safe prophylactic strategy to prevent this unfavorable event. Our murine model presents a novel avenue for the development of adjunct immunomodulatory therapies to perhaps further reduce oncologic risks during laparoscopic management of TCC.

Changes in pH of peritoneal fluid associated with carbon dioxide insufflation during laparoscopic surgery in dogs

OBJECTIVE

To evaluate changes in pH of peritoneal fluid associated with CO2 insufflation during laparoscopy in dogs.

ANIMALS

13 client-owned dogs and 10 purpose-bred teaching dogs.

PROCEDURES

Laparotomy was performed on control dogs; peritoneal fluid pH was measured at time of incision of the abdominal cavity (time 0) and 30 minutes later. Laparoscopic insufflation with CO2 was performed and routine laparoscopic procedures conducted on the teaching dogs. Insufflation pressure was limited to 12 mm Hg. Intraperitoneal fluid pH was measured by use of pH indicator paper at 4 time points. Arterial blood gas analysis was performed at the same time points.

RESULTS

Peritoneal fluid pH did not change significantly between 0 and 30 minutes in the control dogs. For dogs with CO2 insufflation, measurements obtained were a mean of 8.5, 24.5, 44.5, and 72.0 minutes after insufflation. The pH of peritoneal fluid decreased significantly between the first (7.825 +/- 0.350) and second (7.672 +/- 0.366) time point. Blood pH decreased significantly between the first (7.343 +/- 0.078), third (7.235 +/- 0.042), and fourth (7.225 +/- 0.038) time points. The PaCO2 increased significantly between the first (39.9 +/- 9.8 mm Hg) and fourth (54.6 +/- 4.4 mm Hg) time points. Base excess decreased significantly between the first and all subsequent time points.

CONCLUSIONS AND CLINICAL RELEVANCE

Pneumoperitoneum attributable to CO2 insufflation caused a mild and transient decrease in peritoneal fluid pH in dogs. Changes in peritoneal fluid associated with CO2 insufflation in dogs were similar to those in other animals.

Postlaparoscopic Abdominal Port-Site Metastasis: F-18 FDG PET/CT Demonstration

Laparoscopic surgery has expanded its applications to treatment of malignant neoplasms with lower morbidity and mortality compared with the ones carried by conventional procedures. With the increasing volume of this minimally invasive technique, complications such as port-site tumor seeding may have a higher occurrence. Abdominal wall metastasis has been reported with conventional cross-sectional imaging. The authors present 2 cases of early detection of port-site tumor implantation by PET/CT.