A.R. Koh

Standard Surgical Boundary, Surgical Results, and Outcomes of Systemic Laparoscopic Para-Aortic Lymphadenectomy Up to the Left Renal Vein Level for Women With Gynecologic Cancers

Patients: 104 patients had laparoscopic hysterectomy(uteri>500g) with manual morcellation technique. Intervention: The uterus is placed into a polyurethane endoscopic bag intracorporeally. The edges of the bag opening are exteriorized via suprapubic port incision for abdominal extraction or through the vaginal orifice for vaginal extraction. The surgeon uses Lehey clamps to hold the specimen and a scalpel to circumferentially core the specimen. The specimen is extracted in small fragments. The decision for abdominal or vaginal extraction is dependent of the type of hysterectomy performed, specimen size, and presence of vaginal stenosis. Measurements and Main Results: Demographic data for mean age 48.1 years(range 34-69) and BMI 36.94 kg/m2(range 19.1-56.7) were identified. The mean operative time was 216 minutes(range 110-410), mean estimated blood loss was 274.7 mL(range 20-1200 mL), and the mean specimen weight was 806.7 g(range 500-1930). Morcellation was performed by an abdominal approach in 58.7%(61/104) and by a vaginal approach in 41.3%(43/104) of patients. Occult malignancy was identified in 2 patients(1 endometrial adenocarcinoma, 1 uterine sarcoma). There were no complications related to the morcellation technique and no instance of bag rupture or specimen spillage. Conclusion: Manual morcellation within an endoscopic bag is safe and feasible. It allows for large uteri to be approached via a laparascopic route without the risk of vascular and bowel injury from the morcellator blade, spillage of specimen into the abdomen, or tumor dissemination in the case of occult malignancy.

Laparoscopic Fertility-Saving Staging Surgery for Woman With Huge Pelvic Mass

Bladder endometriosis is a rare pathological identity with an estimated prevalence of 1-2 %. We present a surgical video of a 40 year female who presented with symptoms of dysuria,frequency and urgency suprapubic pain during menstruation since last 3 years.Cystoscopy revealed an endometriotic nodule . Laparoscopic resection was planned which included cystoscopy and bilateral uretric stenting and resection of the entire lesion. The lesion approximately 4cm by 3 cm near the left ureteric orifice identified and marked cystoscopically . Simultaneously laparoscopy showed scarring and puckering over the lower part of uterus and bladder. Prevesical spaces were accessed using sharp and careful dissection. Thereafter bladder was distended and nodule excised with Harmonic scalpel. The bladder was sutured in three layers with polygalactin 2-0 in running, non-locking fashion. Patient was kept on foleys catheter drainage for 3 weeks and stents were removed after 6 weeks.