Anil Tailor

Cerebral oedema following robotic surgery: a rare complication

IntroductionWe present an unusual complication following robotic assisted radical hysterectomy.Case reportA 51-year-old female with stage 1B1 cervical cancer underwent a robotic assisted radical hysterectomy. The procedure was prolonged with difficulties dissecting the left parametrium and vaginal fornix with persistent bleeding from the left vaginal vault. Post-operatively the patient was electively sedated and ventilated. Extubation was difficult due to patient agitation but achieved on day 2. Agitation persisted and a head CT scan was performed and a diagnosis of cerebral oedema was made.DiscussionFactors contributing to this case include prolonged operating time, prolonged Trendelenburg position with high pressures of CO2 pneumoperitoneum and excessive blood loss. These factors may contribute to poor cerebral venous outflow, increasing intracranial pressure leading to increased risk of cerebral oedema.ConclusionThe mechanics of robotic assistance may be used to reduce these risks by significantly reducing intra-abdominal pressure improving venous return.SummaryThe use of robotics in surgery has been increasing over the last 10xa0years, and the benefits have been well documented. We present an unusual complication following robotic assisted radical hysterectomy performed for cervical cancer.

First clinical experience of argon neutral plasma energy in gynaecological surgery in the UK

We describe the first in vivo use of neutral argon plasma energy in gynaecological surgery in the UK and the largest series worldwide. The use of PlasmaJet® (PJ) in different applications in 118 selected cases in a tertiary referral centre for gynaecological oncology and minimal access surgery was assessed. The effectiveness, ease of use, ergonomics and safety of PJ in gynaecological surgery is evaluated prospectively. Following this experience, we have devised a table of recommended power settings for different applications.

Robot assisted surgery in gynaecologic oncology – starting a program and initial learning curve from a UK tertiary referral centre: the Guildford perspective

The paper discusses the setup and evaluation of early data following the establishment of a robotic surgery programme in a UK gynaecological oncology cancer centre.

Prevalence of high‐grade CIN following mild dyskaryotic smears in different age groups

Objective:u2002 The new guidelines of the British Society of Colposcopy and Cervical Pathology suggest that women should be offered colposcopy after only one mildly dyskaryotic smear. This is expected to generate increased workload for the colposcopy clinics, at least in the short term. The main objective of this study was to estimate the incidence of high‐grade cervical intraepithelial neoplasia (CIN) in women with mildly dyskaryotic smears and investigate whether there is any variation in different age groups. The rationale was to determine whether we could reduce the burden on colposcopy services by prioritizing the mild dyskaryotic referrals by age, as we hypothesized that high‐grade CIN is less frequent in younger women.

Early experience of laparoscopically assisted radical vaginal hysterectomy (Coelio-Schauta) versus abdominal radical hysterectomy for early stage cervical cancer

The objective of this study was to compare outcomes of laparoscopically assisted radical vaginal hysterectomy (LARVH) vs. abdominal radical hysterectomy (RH) for early-stage cervical cancer. This is a retrospective study of all LARVH and RH procedures between January 2003 and June 2006 in our tertiary referral centre. Demographic, intraoperative and postoperative parameters in both groups were compared. Fourteen women (stage IA2–IB) underwent LARVH, and 12 women (stage IA2 to IB) had RH. All had clear excision margins. None of the laparoscopic procedures were converted into laparotomy. There have not been any recurrences in either group during the follow-up period. We conclude that LARVH and RH are equally efficacious surgical methods. The LARVH group had shorter hospital stay, reduced blood loss, shorter bladder recovery time, less postoperative complications but higher intraoperative injury rate in comparison to RH. This may reflect the learning curve of this new procedure.

Inadvertent insertion of a Foley’s catheter through the orifice of a duplex ureter during catheterisation for laparotomy

We report a case of inadvertent insertion of a 14-Fr Foleys catheter through the orifice of one branch of a previously unrecognised duplex ureter. The unintentional insertion of the catheter occurred at urethral catheterisation during laparotomy for gynaecological malignancy and lead to false intraoperative identification of the female anatomy and injury to the ureter. Postoperatively, cystoscopy and intravenous urography confirmed the existence of a duplex ureter on the affected side.

Intraoperative haemostasis with new fibrin surgical sealant (Quixil®) in gynaecological oncology

Summary We evaluated the effectiveness and safety of Quixil® in gynaecological oncology with a prospective observational study over 11 months in a gynaecological oncology centre. Quixil® was opportunistically used when conventional haemostatic techniques failed, in 35 laparotomies and four laparoscopies. A total of 26 operations were performed for malignant disease and 13 for benign indications. Demographic, intraoperative and postoperative data were collected. Haemostasis was accomplished within 5 min from sealant application. No hypersensitivity reactions were noted. Bowel recovery and postoperative pain were usual. In the laparotomy group, the mean hospital stay was 11 days and mean operating time, 164 min. In the laparoscopy group, the mean hospital stay was 3 days and mean operating time 165 min. In both groups, the incidence of complications and recurrence rates were in line with the expected population rates of these treated patients. We conclude that Quixil® is an efficient, safe and effective haemostatic agent, which has a role to play in gynaecological surgery for benign and malignant disease.

The use of harmonic shears (Ultracision) for laparoscopic lymphadenectomies in women with gynaecological malignancies

The purpose of this paper is to evaluate the safety and efficacy of the harmonic scalpel for laparoscopic pelvic and para-aortic lymphadenectomy in the management of gynaecologic cancers. A prospective study of 21 consecutive patients with gynaecologic cancer, including cervical (11), endometrial (3), ovarian (6) and tubal (1). Eleven patients had pelvic nodes retrieval only, two had para-aortic nodes retrieval only and eight had both. Eighteen patients had transperitoneal lymphadenectomies, one had extraperitoneal and two had both. Eleven patients had a hysterectomy or salpingo-oophorectomy in addition to the laparoscopic lymphadenectomy. In all cases, the harmonic scalpel was used as the only instrument to achieve haemostasis. Average nodal yields were 21.4 for bilateral pelvic lymphadenectomies. The mean estimated blood loss was 132.7xa0ml. There were no intraoperative complications. Laparoscopic pelvic and para-aortic lymphadenectomy using the harmonic scalpel appears to be both safe and efficient in the management of patients with gynaecologic cancers. Its main advantage is that it enables simultaneous and safe tissue dissection, haemostasis and cutting, avoiding the exchange of several instruments. It could become the first choice instrument for this procedure.

Use of neutral plasma coagulation in groin node dissection for vulvar malignancy: a novel technique

Vulvar cancer is an uncommon disease with approximately 1000 cases reported annually in the UK. Lymph node involvement is an important prognostic indicator. Vulvectomy and bilateral groin node dissection are the preferred surgical treatments for early disease and increase survival. However, significant morbidity with lymphocyst formation and wound breakdown has been reported in more than 50% of cases. We report the first case following use of the PlasmaJet® neutral argon coagulation system to reduce postoperative lymphocyst formation.

Decidualisation of ovarian endometriomas in pregnancy: a management dilemma. A case report and review of the literature

IntroductionIncreased progesterone levels during pregnancy may cause decidualisation of endometriomas mimicking malignancies on radiology and causing management dilemmas.CaseAn ovarian cyst was detected in a 33-year-old woman at her routine 12-week gestation ultrasound scan. By 18xa0weeks, the unilocular mass was increasing in size with features suggestive of early ovarian malignancy. The cyst was monitored throughout pregnancy and caesarean section at 38xa0weeks delivered a healthy male. Histology confirmed a decidualised endometrioma and benign dermoid cyst with no evidence of malignancy.Literature ReviewThe evidence for decidualised ovarian endometriomas in pregnancy was explored; 14 papers were identified, which reported 26 cases, excluding our index case. Of the 27xa0cases, 19 (70xa0%) were managed surgically, 4 of which were delayed till caesarean section with concomitant cyst excision; 8 cases were managed conservatively through serial monitoring of the cyst, which spontaneously regressed following delivery.ConclusionSurgical management of the cyst provides histological diagnosis but may introduce risks to mother and fetus; a conservative approach may cause anxiety but limits interventions. Elective caesarean section following monitoring throughout pregnancy may bridge the gap between surgical and purely conservative approaches if appropriate. Limited available evidence makes a definitive decision regarding management difficult. Decidualisation should be considered as a differential for suspicious ovarian lesions in pregnancy.