Laparoscopic lymphadenectomy for gynecologic malignancies using ultrasonically activated shears: analysis of first 100 cases

Evaluating the importance of routine drainage following laparoscopic pelvic lymph node dissection for gynecological malignancies

OBJECTIVE

To determine the efficacy of drainage following pelvic lymph node (PLN) dissection, especially for cases involving laparoscopic surgery.

METHODS

In this retrospective study, 368 patients with malignant gynecological tumors who underwent systemic PLN dissection at Keio University Hospital between January 2012 and October 2018 were enrolled. Drainage tubes were placed in the retroperitoneal fossa in all patients. Medical records were used for data collection.

RESULTS

Laparoscopy was performed on 81 patients, and laparotomy was performed on 287 patients. In the laparoscopy group, tubes were removed 1 day post surgery. In the laparotomy group, tubes were removed 1 day post surgery in 167 patients and 4 days post surgery in 120 patients. Compared with the laparotomy group, we determined the laparoscopy group to have a significantly lower prevalence of lymphocyst (6.2% vs 20.2%, p = 0.002) but a similar prevalence of lymphedema (4.9% vs 5.2%), and symptomatic lymphocyst (2.5% vs 4.5%). The two laparotomy groups did not differ significantly with respect to the prevalence of lymphedema (4.8% vs 5.8%), lymphocyst (20.4% vs 20.0%), or symptomatic lymphocyst (4.2% vs 5.0%).

CONCLUSION

Our results suggest that routine drainage should be omitted, especially in cases involving laparoscopic surgery.

Application of thrombin gel matrix for the prevention of lymphocele in patients with endometrial cancer: A prospective randomized trial

OBJECTIVE

To evaluate a thrombin gel matrix (TGM), Floseal, for the prevention of lymphocele in patients with endometrial cancer who underwent pelvic lymphadenectomy.

METHODS

A total of 79 consecutive patients with endometrial cancer were randomly allocated to one of two groups: the TGM group and control group. After completion of the lymphadenectomy, 5 mL of Floseal was applied to the bilateral pelvic sidewalls, especially the femoral canal, obturator, and common iliac vessels areas. Computed tomography scans were obtained for lymphocele evaluation 2 months after the surgery.

RESULTS

Three patients from the TGM group, and four patients from the control group were lost during follow-up, and data from 36 participants from each group were analyzed. As the primary outcome, lymphocele developed in 12 patients in both groups (33 %). There was no significant difference between the groups in terms of lymphocele and symptomatic lymphocele development. Lymphocele localization was also not different between the two groups, but the diameter of the lymphoceles detected in the TGM group was significantly greater (p = 0.021). The mean drainage days was significantly shorter in the TGM group (p = 0.015). The amount of drainage was also less in the TGM group, but the difference was not statistically significant.

CONCLUSION

Thrombin gel matrix applied to the pelvic sidewalls does not reduce the incidence of symptomatic or asymptomatic lymphoceles after pelvic lymphadenectomy in endometrial cancer. However, it can reduce the amount of drainage and the number of drainage days so it can help to shorten hospitalization.

A collagen-fibrin patch for the prevention of symptomatic lymphoceles after pelvic lymphadenectomy in women with gynecologic malignancies: A randomized clinical trial

OBJECTIVE

To evaluate the efficacy of a collagen-fibrin patch for the prevention of symptomatic lymphoceles after pelvic lymphadenectomy in women with gynecologic malignancies.

METHODS

In a multicenter, randomized, clinical trial, 164 women with pelvic lymphadenectomy were allocated either to bilateral pelvic application of two collagen-fibrin patches or no intervention. Main outcome was efficacy, defined as reduction of symptomatic lymphocele rate diagnosed within four weeks after surgery. Secondary outcomes were asymptomatic lymphoceles and subsequent interventions. Sample size was based on the assumption that application of a collagen-fibrin patch reduces the prevalence of symptomatic lymphoceles by at least 66%. The study was single-blinded, i.e., patients and primary outcome assessors, but not surgeons, were blinded to the treatment allocation.

RESULTS

A total of 75 women were randomized to the intervention and 89 to the control group. All women received the allocated intervention. In total, 42 (27.4%) lymphoceles and 8 (5.2%) symptomatic lymphoceles were observed. Symptomatic lymphoceles were observed in 5/68 (7.4%) women in the intervention group and 3/85 (3.5%) women in the control group (p = 0.47). Asymptomatic lymphoceles were observed in 16 (23.5%) women in the intervention group compared to 18 (21.2%) in the control group (p = 0.85). In a multivariate logistic regression model, no independent risk factor for the development of a symptomatic lymphocele was ascertained.

DISCUSSION

Intraoperative application of collagen-fibrin patches to the pelvic side walls does not reduce the incidence of symptomatic lymphoceles in women with gynecologic malignancies undergoing pelvic lymphadenectomy.

Prevention of lymphocele by using gelatin-thrombin matrix as a tissue sealant after pelvic lymphadenectomy in patients with gynecologic cancers: a prospective randomized controlled study

Objective

This prospective randomized controlled pilot study aimed to find whether gelatin-thrombin matrix used as a tissue sealant (FloSeal) can prevent the occurrence of pelvic lymphocele in patients with gynecologic cancer who has undergone pelvic lymphadenectomy.

Methods

Each patient, who undergo a laparotomic pelvic lymph node dissection on both sides, was randomly assigned for FloSeal application on 1 side of the pelvis. The other side of the pelvis without any product application being the control side. The amount of lymph drainage at each side of the pelvis was measured for 3 days, and computed tomography scans were obtained 7 days and 6 months after surgery for detection of pelvic lymphocele.

Results

Among 37 cases, the median amount of lymph drainage was significantly decreased in the hemi-pelvis treated with FloSeal compared to the control hemi-pelvis (p=0.025). The occurrence of lymphocele was considerably reduced in treated hemi-pelvis (8/37, 21.6%) compared with control hemi-pelvis (12/37, 32.4%) after 7 post-operative days (p=0.219), and more decreased in the treated hemi-pelvis (5/37, 13.5%) compared with control hemi-pelvis (9/37, 24.3%) after postoperative 6 months (p=0.344).

Conclusion

The application of FloSeal as a tissue sealant in lymph nodes resected tissues can reduce the incidence of pelvic lymphocele in gynecologic cancer patients. A large randomized controlled study could confirm these preliminary results.

Use of TachoSil® to Prevent Symptomatic Lymphocele after an Aggressive Tumor Debulking with Lymphadenectomy for Advanced Stage Ovarian Cancer. A Pilot Study

OBJECTIVE

To describe the incidence of symptomatic lymphocele (SLC) after an aggressive tumor debulking surgery and lymphadenectomy in patients with ovarian cancer and peritoneal carcinomatosis with or without TachoSil®.

MATERIAL AND METHODS

A pilot retrospective comparative observational study was performed between patients with advanced ovarian cancer International Federation of Gynecology and Obstetrics stages III-IV who underwent complete debulking surgery and radical retroperitoneal lymphadenectomy. In 18 patients, 4 TachoSil® patches were placed in the retroperitoneal area, since January 2014-October 2014. This group was compared with other 18 consecutive patients matched by age, International Federation of Gynecology and Obstetrics stage, surgical complexity, American Society of Anesthesiologists score, comorbidity, and BMI without the use of TachoSil®.

RESULTS

Baseline characteristics were similar between groups. There were no statistically significant differences in terms of surgical complexity, surgical time, estimated blood loss, node removed, length of hospital stay, and complications between groups. SLC was diagnosed in 7 patients (38.8%) without TachoSil®, and in 2 patients (11.1%) with TachoSil® (p = 0.121). The use of TachoSil® was associated with a statistically significant lower re-admission rate (p = 0.041) and with a significantly shorter time to adjuvant chemotherapy (p = 0.02).

CONCLUSIONS

Using TachoSil® in women with advanced stage ovarian cancer who underwent radical debulking with retroperitoneal lymph node dissection is associated with a non-statistically significant reduction in the incidence of SLC. A larger-scale randomized controlled study should be conducted to confirm our preliminary results.

Does ultrasonic advanced energy reduce lymphocele incidence in laparoscopic para-aortic lymphadenectomy?

OBJECTIVE

To evaluate the use of ultrasonic advanced energy in reducing the occurrence of symptomatic lymphocele and its related complications in laparoscopic extra-peritoneal para-aortic lymphadenectomy in patients with gynecological cancer.

STUDY DESIGN

A retrospective cohort study of consecutive patients in a tertiary referral center identified 2 groups of patients, undergoing laparoscopic extra-peritoneal para-aortic lymphadenectomy with or without the use of ultrasonic advanced energy. Surgery time, hospital stay, number of retrieved nodes and lymphocele requiring treatment were studied. Results were also compared between trained and trainee surgeons.

RESULTS

163 patients were scheduled for laparoscopic extra-peritoneal para-aortic lymphadenectomy: 81 treated using bipolar energy (control group: group 1) between August 1999 and January 2005, and 82 treated using ultrasonic advanced energy (study group: group 2) between July 2010 and March 2014. The main indication (90% in group 1, 61% in group 2) was advanced cervical carcinoma (stage IB2 and above). Ultrasonic advanced energy significantly decreased operative time (p=0.001) and intra-operative bleeding (p=0.01) and increased the number of para-aortic nodes retrieved (p=0.02). There was no significant difference in hospital stay or lymphocele requiring treatment (8.6% in group 1, 8.5% in group 2: p=0.98). For senior than for junior surgeons, surgery time was shorter but not significantly (p=0.80) and postoperative lymphocele rates were identical.

CONCLUSION

Ultrasonic advanced energy may provide benefit in laparoscopic para-aortic lymphadenectomy, facilitating surgical ergonomics, but did not decrease post-surgery lymphocele.

Prevention of lymphoceles using FloSeal and CoSeal after laparoscopic lymphadenectomy in patients with gynecologic malignancies

INTRODUCTION

Pelvic ± para-aortic lymphadenectomy (LAE) is an essential element of staging and treatment of different gynecologic malignancies. However, LAE can induce asymptomatic and symptomatic pelvic lymphoceles (LCs) in a considerable percentage of patients. Therapy of symptomatic LCs may cause additional morbidity. The best strategy to reduce the rate of LCs has not established yet.

MATERIALS AND METHODS

Between January 2011 and May 2012, transperitoneal laparoscopic pelvic ± para-aortic LAE was performed at the Department of Gynecology at Charité University Hospital Berlin in 238 patients with cervical, endometrial, ovarian, or groin-positive vulvar cancer. The application of FloSeal (Baxter, Deerfield, IL) and CoSeal (Baxter) was used in 25 patients (group A) as an alternative to routine pelvic drainage after LAE. A case-control comparison was performed on 25 patients (group B) with bilateral drainage after complete LAE. The primary objective of this pilot study was to evaluate the feasibility and safety of the method. As a secondary objective, we evaluated the incidence of LCs and symptomatic LCs in both groups. The detection of LCs was performed during oncologic follow-up by sonography, computed tomographic imaging, or magnetic resonance imaging.

MEASUREMENTS AND MAIN RESULTS

Pelvic (n = 50) or pelvic + para-aortic (n = 42) LAE was performed in 44 patients with cervical, 2 with endometrial, 1 with ovarian, and 2 with groin-positive vulvar cancer, respectively. In group B (n = 25), systematic bilateral pelvic drainage was placed after finishing LAE, whereas in group A (n = 25) LAE areas were sealed with 5 mL FloSeal on each side and sprayed with CoSeal afterward without placing drains. In 14 of 50 patients (28%), LCs were detected. In a subgroup of patients with cervical cancer (88% of the cohort), symptomatic LCs occurred in 11% in group A and 18% in group B. Operative revision of symptomatic LCs was necessary in 5% and 18% in groups A and B, respectively (p = .66). Mean Hospital stay was significant shorter in group A (6 days) versus B (8 days) (p = .027).

CONCLUSION

The results of this case-controlled pilot study indicate that the application of FloSeal and CoSeal after transperitoneal LAE is feasible and safe, may reduce hospital stay, and may potentially decrease the rate of symptomatic LCs in patients with gynecologic malignancies.

A collagen-fibrin patch (Tachosil®) for the prevention of symptomatic lymphoceles after pelvic lymphadenectomy in women with gynecologic malignancies: a randomized clinical trial

Background

Lymphoceles are a common complication after pelvic lymphadenectomy in women with gynecologic malignancies. Although typically asymptomatic, lymphoceles can superinfect requiring medical or surgical intervention. A single center randomized controlled trial provided first evidence, that a collagen-fibrin patch (Tachosil®) is effective in the prevention of symptomatic lymphoceles after pelvic lymphadenectomy.

Methods/Design

We will perform a multicentre, blinded, randomized, controlled trial comprising 140 women with gynecologic malignancies undergoing pelvic lymphadenectomy. Women will be randomly allocated to Tachosil® application or no application. Primary outcome is efficacy, defined as lymphocele CTCAE 4.03 grade ≥2 within four weeks after surgery. Secondary outcomes are asymptomatic lymphocele verified by ultrasound, medical or surgical intervention. Assuming a two-sided 5% significance level, a power of 80%, and a drop out rate of 10%, a sample size of 68 patients per group was calculated to detect a 66% absolute decrease in symptomatic lymphoceles.

Discussion

We aim to provide further evidence for the efficacy of a collagen-fibrin patch in the prevention of symptomatic lymphoceles in women with gynecological malignancies undergoing pelvic lymphadenectomy.

Trial registration

This study is registered at ClinicalTrials.gov (NCT01470677, protocol ID: TACHO-1). This study is registered at the EudraCT database (EudraCT number: 2011-003115-34).

An overview of uterine cancer and its management

Endometrial cancer is increasingly common in affluent Western countries, largely owing to the growing obesity of those populations. There are two recognized types of endometrial cancer: Type I is more common and is associated with obese postmenopausal women and comprises approximately 80% of all endometrial cancers; Type II describes a woman who is often younger and thinner with a more aggressive histologic type that is nonestrogen dependent, of either serous or clear cell histology, and consists of a more aggressive clinical course and results in poorer prognosis. As the majority of patients with endometrial cancer present with symptoms and have early disease, screening is unlikely to be cost effective or reduce the mortality rate. However, surveillance of high-risk populations is a different proposition. Patients who may benefit from routine surveillance include those with a family history of endometrial cancer, a history of hormone replacement therapy with less than 12-14 days of progestogens, long-term use of tamoxifen, hereditary nonpolyposis colorectal cancer family syndrome, Cowden's syndrome, Peutz-Jeghers syndrome, a history of breast cancer and obesity. Most patients with endometrial cancer are offered surgery as first-line therapy. The standard surgical procedure should be an extrafascial total hysterectomy with bilateral salpingo-oophorectomy. Adnexal removal is also recommended, even if the adnexa appear normal, as they may contain micrometastases. The safety of a laparoscopic approach in the surgical management of uterine cancer has not yet been demonstrated in prospective randomized trials, therefore, the field awaits the Gynaecologic Oncology Group's prospective Lap-2 study. While post-treatment follow-up guidelines vary between institutions and countries, in general, patients at high risk of recurrence are followed closely every 3-4 months for the first year or two, then every 6 months to complete 5 years of follow-up.

Lymphocele Prevention After Pelvic Laparoscopic Lymphadenectomy by a Collagen Patch Coated With Human Coagulation Factors: A Matched Case-Control Study

Objective

Lymphoceles are among the most common postoperative complications of pelvic lymphadenectomy (PL), with a reported incidence of 1% to 50%. Symptoms are pelvic pain, leg edema, gastrointestinal obstruction, obstructive uropathy, and deep vein thrombosis, and severe complications such as sepsis and lymphatic fistula formation. After laparoscopic PL, we tested the prevention of lymphoceles using collagen patch coated with the human coagulation factors (TachoSil, Nycomed International Management GmbH, Zurich, Switzerland) on 55 patients with endometrial cancer stages IB to II who had undergone laparoscopy.

Materials and Methods

The authors divided the patients into 2 laparoscopy groups: PL plus TachoSil (group 1: 26 patients) and PL without TachoSil in a control group (group 2: 29 patients), as historical cohort of patients who underwent PL between 2010 and 2012. We collected surgical parameters, and the patients underwent ultrasound examination on postoperative days 7, 14, and 28. The main outcome measures were the development of symptomatic or asymptomatic lymphoceles, the need for further surgical intervention, as adverse effect of surgery, and the drainage volume and duration.

Results

The same number of lymph nodes in both groups was removed; group 1 showed a lower drainage volume. Lymphoceles developed in 5 patients in group 1 and in 15 patients in group 2; of these, only 2 patients were symptomatic in group 1 and 5 patients were symptomatic in group 2, without statistical difference and no percutaneous drainage request.

Conclusions

In this preliminary investigation, the intraoperative laparoscopy application of TachoSil seems to reduce the rate of postoperative lymphoceles after PL, providing a useful additional treatment option for reducing drainage volume and preventing lymphocele development after PL.

Complications of lymphadenectomy for gynecologic cancer

INTRODUCTION

Symptomatic postoperative lymphocysts (SPOLs) and lower-limb lymphedema (LLL) are probably underestimated complications of lymphadenectomy for gynecologic malignancies. Here, our objective was to evaluate the incidence and risk factors of SPOLs and LLL after pelvic and/or aortocaval lymphadenectomy for gynecologic malignancies.

METHODS

Single-center retrospective study of consecutive patients who underwent pelvic and/or aortocaval lymphadenectomy for ovarian cancer, endometrial cancer, or cervical cancer between January 2007 and November 2008. The incidences of SPOL and LLL were computed with their 95% confidence intervals (95%CIs). Multivariate logistic regression was performed to identify independent risk factors for SPOL and LLL.

RESULTS

We identified 88 patients including 36 with ovarian cancer, 35 with endometrial cancer, and 17 with cervical cancer. The overall incidence of SPOL was 34.5% (95%CI, 25-45) and that of LLL was 11.4% (95% confidence interval [95%CI], 5-18). Endometrial cancer was independently associated with a lower risk of SPOL (adjusted odds ratio [aOR], 0.09; 95%CI, 0.02-0.44) and one or more positive pelvic nodes with a higher risk of SPOL (aOR, 4.4; 95%CI, 1.2-16.3). Multivariate logistic regression failed to identify factors significantly associated with LLL.

CONCLUSION

Complications of lymphadenectomy for gynecologic malignancies are common. This finding supports a more restrictive use of lymphadenectomy or the use of less invasive techniques such as sentinel node biopsy.

Literature review of the energy sources for performing laparoscopic colorectal surgery

Laparoscopic surgery for colorectal disease has become widespread as a minimally invasive treatment. This is important because the increasing availability of new devices allows us to perform procedures with a reduced length of surgery and decreased blood loss. We herein report the results of a literature review of energy sources for laparoscopic colorectal surgery, focused especially on 6 studies comparing ultrasonic coagulating shears (UCS) and other instruments. We also describe our laparoscopic dissection techniques using UCS for colorectal cancer. The short-term outcomes of surgeries using UCS and Ligasure for laparoscopic colorectal surgery were superior to conventional electrosurgery. Some authors have reported that the length of surgery or blood loss when Ligasure was used for laparoscopic colorectal surgery is less than when UCS was used. On the other hand, a recent study demonstrated that there were no significant differences between the short-term outcomes of UCS and Ligasure for laparoscopic colorectal surgery. It is therefore suggested that the choice of technique used should be made according to the surgeon’s preference. We also describe our laparoscopic dissection techniques using UCS (Harmonic ACE) for colorectal cancer with regard to the retroperitoneum dissection, dissection technique, dissection technique around the feeding artery, and various other dissection techniques. We therefore review the outcomes of using various energy sources for laparoscopic colorectal surgery and describe our laparoscopic dissection techniques with UCS (Harmonic ACE) for colorectal cancer.

Postoperative pancreatic fistula and the risk factors of laparoscopy-assisted distal gastrectomy for early gastric cancer

BACKGROUND

Laparoscopy-assisted distal gastrectomy (LADG) was introduced as minimally invasive surgery for early gastric cancer (EGC) in Japan. This study investigated postoperative pancreatic fistula (POPF) and associated risk factors of the procedure.

METHODS

From January 2005 to December 2009, 798 patients with EGC diagnosed before surgery underwent LADG. Thirty-four patients developed postoperative pancreatic fistula (POPF group), whereas the other 764 patients did not experience POPF (NPOPF group). POPF was defined and graded according to the International Study Group on Pancreatic Fistula Definition (ISGPF). Patient characteristics and operative and postoperative outcomes were compared between the two groups. Risk factors associated with POPF were analyzed.

RESULTS

POPF occurred in 34 (4.3%) patients; among them 3 developed grade C POPF, a complication that required aggressive clinical intervention, and only 1 underwent reoperation. Compared with the NPOPF group, the POPF group had higher percentage of male patients (88.2% vs. 60.5%, P = 0.001), higher mean body mass index (24.8 ± 2.5 kg/m(2) vs. 22.5 ± 3.2 kg/m(2), P < 0.001), longer mean operation time (251.3 ± 46.7 min vs. 229.7 ± 53.9 min, P = 0.022), higher postoperative complications (100% vs. 8.6%, P < 0.001), and longer mean postoperative hospital stay (29.6 ± 19.9 days vs. 12.6 ± 6.7 days, P < 0.001). Univariate and multivariate analysis identified sex and body mass index as risk factors associated with POPF after LADG.

CONCLUSIONS

LADG can be performed safely in patients with EGC in terms of the low incidence of POPF. To decrease the risk of POPF, LADG should be performed cautiously in male patients with high body mass index.

Ultrasonic shears in free-tissue transfer: increased efficiency and cost savings

OBJECTIVE

The harvest of some microvascular free flaps for head and neck reconstruction entails tedious and time-consuming dissection of multiple perforating vessels and/or muscular attachments. The objective of this study is to investigate the use of ultrasonic shears as a means to decrease operative time and increase surgical efficiency in the harvest of microvascular free flaps.

STUDY DESIGN

Prospective cohort study.

SETTING

Tertiary referral center.

SUBJECTS AND METHODS

A prospective study of all people undergoing fibula (FFF) or anterolateral thigh (ALT) free flap reconstruction of head and neck defects was conducted from October 1, 2005, through December 30, 2009.

RESULTS

There were 69 FFF and 39 ALT free flaps performed by a single surgeon during the study period. Ultrasonic shears were used in 53 (76.8%) FFF and 26 (80.6%) ALT free flaps, whereas traditional dissection techniques were used in 16 (23.2%) FFF and 13 (19.4%) ALT free flaps. The use of ultrasonic shears significantly decreased the harvest time of FFF and ALT free flaps an average of 14.5 and 16.3 minutes, respectively. The average cost savings associated with the use of ultrasonic shears was $492 for FFF and $543 for ALT free flaps compared to traditional dissections techniques. Similar rates of complications were observed when ultrasonic shears were used compared to traditional techniques.

CONCLUSIONS

The use of ultrasonic shears in the harvest of microvascular free flaps decreases operative time, leading to significantly decreased costs without an increased risk of complications compared to traditional dissection techniques.

Feasibility, safety, and cost outcomes of laparoscopic management of early endometrial and cervical malignancy

BACKGROUND

The role of laparoscopy in the management of early stage endometrial and cervical cancer is continuously validated by many reports throughout the world. Interestingly, such data are still unavailable in many European countries, as it is in Greece. In this prospective study, we report on initial feasibility, safety, and cost outcomes of laparoscopic management of early stage endometrial and cervical cancer, recently introduced in our country.

MATERIALS AND METHODS

This was a prospective pilot study comprising a case series. Patients referred to a tertiary referral medical center with a recent diagnosis of endometrial or cervical cancer were evaluated, and those meeting inclusion criteria were offered laparoscopic surgical staging.

RESULTS

Out of 64 patients evaluated, 17 with early clinical stage endometrial cancer and 8 with early clinical stage cervical cancer underwent successful laparoscopic staging. Mean patient age was 61.6 and 39.2 years, mean BMI was 32.3 and 24.1kg/m(2), mean operative time was 243 and 284 minutes, mean estimated blood loss was 190mL and 270mL, mean lymph node count was 27.2 and 29.1, and mean hospital stay was 2 and 3 days for endometrial and cervical cancer cases, respectively. The overall costs for the procedures performed were not greater than their laparotomy counterpart. One intraoperative complication was managed laparoscopically, and 2 cases occurred of postoperative lymphocyst formation.

CONCLUSION

To our knowledge, this is the first study of laparoscopic management of early endometrial and cervical cancer in Greece. Our preliminary data support the feasibility, safety, and cost effectiveness of laparoscopic management of early endometrial and cervical cancer in our country and are in accordance with series reported in the international literature.

A comparative study of laparoscopic extraperitoneal lymphadenectomy [correction of laparoscopy] with the use of ultrasonically activated shears

OBJECTIVE

We evaluated the use of the harmonic scalpel in reducing the occurrence of symptomatic lymphoceles and its related complications in paraaortic laparoscopic lymphadenectomies (PALLs).

STUDY DESIGN

All PALL that were performed at the Institut Claudius Regaud between January 2003 and June 2007 were included. Since January 2006, the harmonic scalpel has been used systematically for all lymphostasis. Lymphoceles that required treatment were recorded as a complication.

RESULTS

Ninety-eight patients were enrolled, 62 PALLs were performed with the standard technique (control group), and 36 PALLs were performed with the harmonic scalpel (study group). There were no differences regarding operating time, blood loss, median nodal yield, and duration of hospital stay. Seven patients of the control group vs none of the study group (P = .03) experienced a symptomatic lymphocele that required medical treatment; 4 patients had radiologic drainage, and 1 patient had surgical drainage.

CONCLUSION

We demonstrate the efficacy of harmonic scalpel in reducing the occurrence of symptomatic lymphoceles in paraaortic extraperitoneal lymphadenectomy.

A case-controlled study of total laparoscopic radical hysterectomy with pelvic lymphadenectomy versus radical abdominal hysterectomy in a fellowship training program

To determine whether total laparoscopic radical hysterectomy (TLRH) is a feasible alternative to an abdominal radical hysterectomy (ARH) in a gynecologic oncology fellowship training program. We prospectively collected cases of all of the patients with cervical cancer treated with TLRH and pelvic lymphadenectomy by our division from 2000 to 2006. All of the patients from the TLRH group were matched 1:1 with the patients who had ARH during the same period based on stage, age, histological subtype, and nodal status. Thirty patients were treated with TLRH with a mean age of 48.3 years (range, 29–78 years). The mean pelvic lymph node count was 31 (range, 10–61) in the TLRH group versus 21.8 (range, 8–42) (P < 0.01) in the ARH group. Mean estimated blood loss was 200 cc (range, 100–600 cc) in the TLRH with no transfusions compared to 520 cc in the ARH group (P < 0.01), in which five patients required transfusions. Mean operating time was 318.5 min (range, 200–464 min) compared to 242.5 min in the ARH group (P < 0.01), and mean hospital stay was 3.8 days (range, 2–11 days) compared to 5.6 days in the ARH group (P < 0.01). All TLRH cases were completed laparoscopically. All patients in the TLRH group are disease free at the time of this report. In conclusion, it is feasible to incorporate TLRH training into the surgical curriculum of gynecologic oncology fellows without increasing perioperative morbidity. Standardization of TLRH technique and consistent guidance by experienced faculty is imperative.

Combined laparoscopic and radical vaginal treatment of primary vaginal leiomyosarcoma in a patient with unicornuate uterus and pelvic kidney

We report a case of primary vaginal leiomyosarcoma occurring in a patient with a unicornuate uterus and pelvic kidney. The patient was treated with radical partial vaginectomy, unilateral groin dissection, total laparoscopic hysterectomy, and left pelvic laparoscopic lymphadenectomy, followed by adjuvant chemotherapy. Twenty-five months after her original procedure, the patient is alive and free of disease. The exact association between müllerian anomalies and primary malignancies of the genitourinary tract is unclear. It is nonetheless important to be aware of the close embryonic association between the genital and urinary tracts when evaluating such patients and choosing the appropriate surgical and therapeutic approach.

In vivo comparison of the coagulation capability of SonoSurg and Harmonic Ace on 4 mm and 5 mm arteries

INTRODUCTION

Ultrasonic dissectors are useful to ligate arteries, but their effectiveness on larger arteries has not been thoroughly documented in vivo. The purpose of this study is to determine the bursting pressure of sealed arteries and the incidence of failure to adequately seal 4 mm and 5 mm arteries in a porcine model using two commercially available ultrasonic coagulators.

METHODS

The splenic, renal, superior mesenteric and carotid arteries of 60 kg swine were dissected and sealed alternating between SonoSurg (SS), 70% output (Olympus Surgical America) and Harmonic Ace (HA), level 3, (Ethicon Endosurgery). The burst pressures of each sealed segment was measured by subjecting them to infusion of water at 50 ml/hr until the seal burst. The mean burst pressure, incidence of burst pressure less than 360 mm Hg and incidence of not sealing were calculated and compared with the t and chi-square tests. Significance was assumed at p = 0.05.

RESULTS

Each instrument was used to divide 44 arteries measuring between 4 and 5 mm (4.7 +/- 0.48 mm vs. 4.7 +/- 0.44 mm, p = NS, SS vs. HA, respectively) in diameter. The burst pressure (900.2 +/- 574.9 mmHg vs. 896.6 +/- 481.0 mmHg, p = NS) was not different comparing SS with. HA. Four vessels (9.1%) failed to seal with each instrument and resulted in immediate hemorrhage. Including the vessel that failed to seal initially, five vessels (11.4%) ligated with SS and six (13.6%) ligated with HA had burst pressure less than 360 mm Hg. This incidence of inadequate sealing was not significantly different between the two instruments when compared with chi-square analysis.

CONCLUSION

SS and HA seal 4-5 mm arteries with similar burst pressures. There is no difference in the incidences of failure to initially seal the arteries or in bursting pressure <360 mmHg in 4-5 mm arteries in the porcine model.

Is laparoscopically assisted radical vaginal hysterectomy for cervical carcinoma safe? A case control study with follow up

OBJECTIVE

To compare a new surgical approach, laparoscopically assisted radical vaginal hysterectomy (LARVH) with open radical hysterectomy in women with cervical cancer. Can selected women benefit from the minimally invasive approach without compromising safety (recurrence rate) and morbidity (complications)?

DESIGN

Retrospective case control study.

SETTING

A tertiary referral unit for gynaecological malignancies.

POPULATION

Thirty women undergoing LARVH were included and compared with 30 women undergoing open radical surgery. The control group was matched for age, body mass index and disease stage.

METHODS

Retrospective collection of data from patient files and follow up.

MAIN OUTCOME MEASURES

Recurrence rate, complication rate, hospital stay, nodal counts, blood loss, operating time.

RESULTS

Recurrence rates were equal (6.7%). There was one death, in the LARVH group. Follow up was mean 31 months in the LARVH group and 30.9 months in the open group. Blood loss as measured by mean drop in haemoglobin was greater in the open group (2.03 versus 3.01 g/dl, P = 0.02). Transfusions were given in 40% of women in the open group and 16.7% in the LARVH group. Hospital stay was significantly less in the LARVH group (5.9 versus 7.8 nights, P = 0.003). Mean operating time was longer in the LARVH group (131 versus 187 minutes P = 0.0001). Mean nodal counts did not differ significantly (17.4 in open vs 14.8 in LARVH, P > 0.05). There were seven perioperative complications in the open group and four in the LARVH group. There have been two recurrences in each group (6.67%) at mean follow up of 31 (LARVH) and 30.9 (open) months.

CONCLUSIONS

The first 30 LARVH procedures performed in this unit are comparable in terms of safety (recurrence rate and complication rate) and economic factors (shorter hospital stay mitigating longer operating time). Further development of this technique is warranted.

Endometrial cancer and its management

Endometrial cancer is an increasingly common cancer in affluent Western countries, largely due to the increasing obesity of those populations. Type I endometrial cancer is the more common phenotypic picture, being that of an obese postmenopausal woman, and comprises approximately 80% of endometrial cancers. Type II endometrial cancer describes a woman who is often younger and thinner, with a more aggressive histological type that is non-estrogen dependent, of either serous or clear-cell histology, and has a more aggressive clinical course and resultant poorer prognosis. The standard surgical procedure is an extrafascial total hysterectomy with bilateral salpingo-oophorectomy, with or without pelvic and para-aortic lymphadenectomy. The safety of a laparoscopic approach in the surgical management of uterine cancer has not yet been demonstrated in prospective randomized trials. Surgical staging of endometrial cancer, including a pelvic and para-aortic lymphadenectomy, allows appropriately tailored postoperative radiotherapy. Teletherapy or vaginal brachytherapy may reduce the risk of pelvic recurrent disease in high-risk patients.

Transperitoneal laparoscopic pelvic and paraaortic lymphadenectomy in gynecologic cancers

Laparoscopy, a minimally invasive surgery, may benefit select patients more than traditional abdominal approaches. The benefits of this procedure include low morbidity, shorter length of hospital stay, less blood loss, no significant increase in complications, and a shorter postoperative recovery period; this allows patients to begin adjuvant therapy more quickly. Laparoscopy has been used in gynecologic oncology since the early 1990s and has continued to grow and develop. Complex gynecologic oncology procedures can be performed with a low rate of complication and a low rate of conversion to laparotomy. The literature supports the fact that laparoscopy can be performed with short-term benefit with no increase in morbidity. Although the data are limited and emerging, the risk of cancer recurrence does not appear to increase because of this minimal access approach. Currently, advanced laparoscopic techniques are used to evaluate and treat cervical, endometrial, and ovarian malignancies. Specifically, transperitoneal laparoscopic lymphadenectomy including pelvic and paraaortic nodes is a feasible and efficacious procedure in the management of certain gynecologic malignancies.