Endoscopic surgery. The end of classic surgery?

Instrument usage in laparoscopic gynecologic surgery: a prospective clinical trial

PURPOSE

To evaluate instrumental usage in laparoscopic gynecological surgeries and to develop key timesets of a laparoscopic operation, which allows categorization of the operation time into different sections.

METHODS

In this prospective clinical observational study, frequency of instrument usage, time for instrument switches, and instrument utilization time were recorded in a standardized manner for laparoscopic surgeries in 103 endoscopic surgeries.

RESULTS

A standard equipment (including atraumatic grasping forceps, irrigation and suction device, bipolar clamp, and laparoscopic scissors) was used for nearly all interventions. Bipolar clamps and scissors were changed most frequently. The tool used for the longest amount of time was the atraumatic grasping forceps. Laparoscopic instruments were switched 51 times per surgery (range 2-250 times). One instrument switch lasted for a median of 0.13 min (0.08-1.2 min). Median time for instrument switch for a single surgery added up to 6.83 min. Instrument switches required 10.5% of the overall operation time.

CONCLUSION

We analyzed the current instrument usage in laparoscopic gynecological surgeries. The results of our standardized investigation suggest ways to reduce the time required for surgery and provide starting points for the standardization of the work routine.

Selective incorporation of total laparoscopic hysterectomy for adnexal pathology and body mass index

OBJECTIVES

We studied patients undergoing adnexectomy with total laparoscopic hysterectomy (TLH) for ovarian pathology, over a 6-year period.

METHODS

Chart abstraction, analyzed by ANOVA, Fisher's Exact Test with significance at P < 0.05, stratifying by body mass index (BMI, kg/m(2): ideal < 25; overweight 25-29.9; obese 30+).

RESULTS

Of 354 patients undergoing TLH, 90 cases had adnexal pathology: 69 complex masses, 16 BRCA1/2 mutations, 5 unstaged ovarian carcinomas; 48 having ideal BMI, 26 overweight, and 16 obese. Mean age (51 years) and parity (1.2 children) were similar between BMI groups. Thirty-four percent were nulliparous. All 90 underwent TLH, adnexectomy, washings; with 14 appendectomies, 5 lymphadenectomies, 3 node samplings, 6 omentectomies, 8 ureterolyses, and 1 Burch. Mean surgery duration (156 min), blood loss (152cc), and hospital stay (1.9 days) were similar across BMI groups. Mean nodal yield from each lymphadenectomy was 14, and 2.6 from sampling. Mean size of pelvic masses was 8 cm (range 3-19 cm). There were seven cases of ovarian carcinoma: 2 Stage IA, 1 IB, 2 IC, 1 IIC, 1 IIIB; 1 recurrent breast cancer, 16 adenofibromas, 15 endometriomas, 10 dermoids, and 41 serous/mucinous cystadenomas. Mean complication rate was 6.6% (ns): 1 seroma, 1 hematoma, 1 obstructive adhesions, and 3 urological injuries. All urological injuries were within the first third of patients.

CONCLUSIONS

TLH appears feasible for women with adnexal pathology regardless of BMI, in an oncological practice. This pilot data can facilitate guidelines for a randomized controlled trial of TLH with TAH and LAVH, and help surgeons avoid our early complications.

Saline contrast sonohysterography in the preoperative assessment of benign intrauterine disorders

OBJECTIVES

To assess the value of saline contrast sonohysterography (SCSH) in the preoperative evaluation of benign intrauterine lesions.

DESIGN

Patients presenting with abnormal bleeding related to benign uterine pathologies and scheduled for surgical treatment were prospectively enrolled in a study conducted between 1 January 1996 and 31 December 1997. SCSH was first carried out with the intention of establishing further surgical management (hysterectomy or hysteroscopy). The end point of the study was to compare the surgical option ultimately carried out with the one decided after SCSH. In addition, size and location of intrauterine lesions determined by SCSH were compared with those issued from surgical records. Similarly, pathologic results were juxtaposed to SCSH diagnosis. Statistical analysis used non-parametric and correlation tests.

RESULTS

Two hundred and thirty-three patients were included in the study, 39.5% of whom were postmenopausal. SCSH was consistently effective in the choice of the best surgical method, because no hysterectomy was required when an operative hysteroscopy was indicated on SCSH data. Similarly, only one patient treated by hysterectomy (5.8%) could have undergone a more conservative approach. But this patient had a genital prolapse, and thus hysterectomy was a part of the treatment. SCSH correlated well with surgery for the location and size of intrauterine lesions (P < 0.001). SCSH was accurate in the diagnosis of polyps and submucous myomas (sensitivity 85.7%, specificity 95.4%).

CONCLUSIONS

SCSH appears an important tool for preoperative assessment of benign intrauterine pathologies. It should be used in the selection of patients that should be scheduled for an operative hysteroscopy.

Photocurable surgical tissue adhesive glues composed of photoreactive gelatin and poly(ethylene glycol) diacrylate

This article presents a novel photochemically driven surgical tissue adhesive technology using photoreactive gelatins and a water-soluble difunctional macromer (poly(ethylene glycol) diacrylate: PEGDA).The gelatins were partially derivatized with photoreactive groups, such as ultraviolet light (UV)-reactive benzophenone and visible light-reactive xanthene dye (e.g., fluorescein sodium salt, eosin Y, and rose bengal). A series of the prepared photocurable tissue adhesive glues, consisting of the photoreactive gelatin, PEGDA, and a saline solution with or without ascorbic acid as a reducing agent, were viscous solutions under warming, and their effectiveness was evaluated as hemostasis- and anastomosis-aid in cardiovascular surgery. Regardless of the type of photoreactive groups, the irradiation of the photocurable tissue adhesive glues by UV or visible light within 1 min produced water-swollen gels, which had a high adhesive strength to wet collagen film. These were due to the synergistic action of photoreactive group-initiated photo-cross-linking and photograft polymerization. An increase in the irradiation time resulted in increased gel yield and reduced water swellability. A decrease in the molecular weight of PEGDA and an increase in concentration of both gelatin and PEGDA resulted in reduced water swellability and increased tensile and burst strengths of the resultant gels. In rats whose livers were injured with a trephine in laparotomy, the bleeding spots were coated with the photocurable adhesive glue and irradiated through an optical fiber. The coated solution was immediately converted to a swollen gel. The gel was tightly adhered to the liver tissue presumably by interpenetration, and concomitantly hemostasis was completed. The anastomosis treatment with the photocurable glue in the canine abdominal or thoracic aortas incised with a knife resulted in little bleeding under pulsatile flow after declamping. Histological examination showed that the glues photocured on rat liver surfaces were gradually degraded with time in vivo with infiltration of inflammatory cells and connective tissues without necrotic sign in surrounding tissue. In addition, in the laparoscopic surgery, percutaneous delivery of the glue and its in situ photogelation on rat liver surfaces were demonstrated using a specially designed fiberscope. These results indicate that the photocurable glues developed here may serve as a biodegradable tissue adhesive glue usable in cardiovascular surgery and endoscopic surgery.