Benoit Rabischong

Laparoscopic management of adnexal masses: a gold standard?

PURPOSE OF REVIEW To review recent literature on the laparoscopic management of adnexal masses, when this approach may be considered as a gold standard. RECENT FINDINGS Cyst rupture was recently demonstrated to be a significant prognostic factor in stage I invasive epithelial carcinoma, and it was recommended to restrict the laparoscopic approach to patients with preoperative evidence that the cyst was benign. The laparoscopic approach is still highly controversial in masses suspicious at ultrasound. The limits of the laparoscopic approach are discussed reviewing recent literature and our experience. The laparoscopic management of adnexal masses appears to be safe in most hospitals even in developing countries. This approach is being used with increasing frequency in unusual indications such as newborns, children, adolescents and pregnant women. The learning curve for endoscopic surgery appears to be longer than expected. Many patients with benign adnexal masses, such as ovarian endometrioma, are still treated by laparotomy or with an inadequate endoscopic technique. Several studies have suggested that the stripping technique is a tissue-sparing procedure. SUMMARY The laparoscopic puncture of malignant ovarian tumours confined to the ovaries is uncommon, and should be avoided whenever possible. The teaching of endoscopy is essential to promote adequate procedures performed according to the principles of microsurgery and to preserve postoperative ovarian physiology.

“Iatrogenic” Parasitic Myomas: Unusual Late Complication of Laparoscopic Morcellation Procedures

STUDY OBJECTIVE To describe our experience in diagnosing and managing parasitic myomas developing as an unexpected late complication of laparoscopic morcellation. DESIGN Observational study (Canadian Task Force classification II-3). SETTING University hospital. PATIENTS Retrospective chart review of all patients found to have parasitic myomas that developed after previous morcellation. INTERVENTION Laparoscopic morcellation. Review of the recent literature correlated with clinical, surgical, and pathologic features of our cases. MEASUREMENTS AND MAIN RESULTS Four patients had heterogeneous pelvic masses after morcellation. In 3 patients, symptoms developed between 2 and 16 years after the primary surgery. One patient had no symptoms, and was referred because of a suspect pelvic mass. Vaginal examination revealed painful pelvic masses in the pouch of Douglas in 2 patients, and painless masses fixed to the vaginal vault and anterior vaginal wall, respectively, in the other 2 patients. Laparoscopic examination confirmed the presence of parasitic masses in 3 patients. In 1 patient, the mass was excised vaginally. Histologic analysis confirmed leiomyoma fragments in all patients. A well-differentiated endometrial carcinoma was incidentally found in 1 patient after hysterectomy. CONCLUSION These masses probably resulted from growth of missed fragments of uterine tissue after previous morcellation, culminating in development of symptomatic iatrogenic parasitic myomas. If morcellation is anticipated or required, exclusion of malignancy is mandatory. Meticulous inspection of the abdominal cavity is necessary after morcellation. In patients with a history of morcellation who have pelvic masses, iatrogenic parasitic myomas should be considered in the differential diagnosis.

Risk of spread of ovarian cancer after laparoscopic surgery.

The incidence of the spread of ovarian cancer after laparoscopic surgery is difficult to establish from the current literature. The prognosis incidence of a trocar site metastasis without peritoneal dissemination is not known. Data from general surgeons in prospective studies from a single institution suggested that in colon cancer the risk is low, whereas it seems to be much higher in multicentric studies of undiagnosed gallbladder cancer. Experimental studies suggested that laparoscopy has advantages and disadvantages. However, the risk of dissemination is high when a large number of malignant cells and a carbon dioxide pneumoperitoneum are present, a situation encountered when managing adnexal tumours with large vegetations. Animal studies will allow the development of a peritoneal environment adapted to the treatment of cancer. The ovary is an intraperitoneal organ and ovarian cancer a peritoneal disease, so the risk of peritoneal spread may be higher in ovarian cancer than in other gynecological cancers. A careful preoperative evaluation appears to be the best way to prevent these risks. It should also be used to choose which patient should be operated by which surgical team. The second step is a careful and cautious laparoscopic diagnosis, so that more than 98% of ovarian cancers encountered can be treated immediately and effectively. The laparoscopic management of ovarian cancer remains controversial; it should be performed only in prospective clinical trials. Until the results of such studies become available, an immediate vertical midline laparotomy remains the gold standard if a cancer is encountered.

Incidence of intraabdominal adhesions in a continuous series of 1000 laparoscopic procedures

OBJECTIVE The objective of the study was the laparoscopic evaluation of the incidence of intraabdominal adhesions related to prior abdominal surgery. STUDY DESIGN This was a prospective monocentric study including a continuous series of 1000 gynecologic laparoscopic procedures. Data were collected on history of abdominal surgery. A precise initial description of intraoperative adhesions was performed. RESULTS Six hundred thirty-seven of the 1000 procedures (63.7%) were performed in patients with a history of 1 or more than 1 abdominal surgery. Intraoperative adhesions were found in 211 of the 1000 subjects (21.10%). Fifty-nine of the 211 cases (28%) involved bowel loops. The prior indication for surgery did not seem to influence adhesion formation. The rate of intestinal adhesions significantly increased with the number of prior abdominal surgeries. The rate of intestinal adhesions was significantly higher in cases of prior midline incisions in comparison with the other incisions. CONCLUSION Extensive preoperative knowledge of prior surgery is essential to evaluate the risk of adhesion formation.

Frozen Section in Laparoscopic Management of Macroscopically Suspicious Ovarian Masses

STUDY OBJECTIVE To study the usefulness of and applications for frozen section in the laparoscopic management of adnexal masses. DESIGN Historical prospective study (Canadian Task Force classification II-3). SETTING Large tertiary care hospital with university affiliation. PATIENTS One hundred forty-one women undergoing laparoscopy for a suspicious adnexal mass. INTERVENTION Adnexal masses suspicious on ultrasound were managed by laparoscopy. After laparoscopic diagnosis, frozen sections were used to confirm a diagnosis of malignancy. Treatment was performed by laparoscopy whenever feasible. MEASUREMENTS AND MAIN RESULTS The results of frozen section were compared with the results of permanent sections, and the consequences of the intraoperative diagnosis on the surgical management were evaluated. The frozen section diagnosis was correct in 125 of the 141 patients (88.7%). In one patient, the result was false negative. Specifically, frozen section diagnosis was correct in 96.8% of cases when a cyst or biopsy was sent for pathologic examination and in 86.4% when the whole adnexa was sent. It was correct in 93% of the cases involving tumors smaller than 100 mm and in 74% of larger tumors. It was correct in 92.3% of the women younger than 50 years and in 81.6% of women older than age 50. Intraoperative pathologic diagnosis was correct in 95.5% of benign tumors, 77.8% of low-malignancy tumors, and 75% of cancer cases. CONCLUSION Frozen section is a useful examination for surgical management decision making; however, the limitations and the difficulties should be taken into account.

Total Laparoscopic Hysterectomy and Early Discharge: Satisfaction and Feasibility Study

STUDY OBJECTIVE Whether, after laparoscopic hysterectomy (LH), selected patients may be safely and comfortably discharged on postoperative day 1 (day after surgery) using specific anesthesia and analgesia protocols that included Post Anesthetic Discharge Scoring System. DESIGN A prospective feasibility pilot study (Canadian Task Force classification II-3). SETTING A French tertiary care hospital. PATIENTS A total of 35 patients who underwent total LH were selected using preestablished criteria based on age, surgical history, place of residence, and capacity to follow instructions. INTERVENTIONS All patients had a telephone call the second and seventh day after surgery. MEASUREMENTS AND MAIN RESULTS Of 35 patients, 34 (97.1%) left the hospital the day after surgery. One patient was not discharged on surgeons instructions, because of technical difficulties during the procedure. Two patients (6.7%) required readmission because of complications. The first patient required hospitalization for vesicovaginal fistula at day 10 and had to undergo laparoscopic treatment of the fistula. The second consulted for hyperthermia at day 4 with suggestion of cuff cellulitis, and was discharged after 2 days of antibiotic treatment. Of 35 women, 34 (97.1%) were satisfied with the procedure and all would recommend it to other patients. CONCLUSION Using our protocol for analgesia, anesthesia, and early discharge (24 hours after surgery) may be safely proposed after total LH in selected patients. Satisfaction rate of patients on postoperative days 7 and 30 was very high.

Proximal ectopic pregnancy: a descriptive general population-based study and results of different management options in 86 cases

OBJECTIVE To describe different approaches for diagnosis and management of proximal ectopic pregnancies (PP) in general population. DESIGN Observational population based-study. SETTING Regional ectopic pregnancy registry. PATIENT(S) Eighty-six PP registered from 1992 to 2008. INTERVENTION(S) Surgical (radical or conservative), medical, or combined therapies. MAIN OUTCOME MEASURE(S) Epidemiologic characteristics, clinical presentation, hCG level, treatments performed, failure rate, and recurrence. RESULT(S) Mean gestational age was 48.2 days. Estimated incidence of PP was 2.7%. Abdominal pain and vaginal bleeding were the commonest symptoms. Two patients were admitted in hypovolemic shock. Diagnostic modalities included transvaginal ultrasound, abdominal ultrasonography, and laparoscopy in 38 (44%), 7 (8%), and 39 (45%) cases, respectively. Mean hCG level was 10,759 IU/L. Thirty-four patients underwent primary cornual resection (39.5%) by laparoscopy (n = 32) or laparotomy (n = 2). Twenty-seven patients (31.4%) underwent primary conservative surgery by laparoscopy: cornuostomy (n = 18) or extended salpigostomy (n = 9). Primary medical treatment with methotrexate was attempted in 14 patients (16.3%). Expectant management was attempted in one case (1.2%). Eleven cases received combined therapies (11.6%). Failure rates for medical and surgical treatments were 35.7% and 28%, respectively. No failures were noted among patients who received combined therapies. CONCLUSION(S) Proximal ectopic pregnancy remains a life-threatening condition. Diagnosis is challenging and requires a high index of suspicion. Despite available conservative strategies, management of PP remains heterogeneous.

Educational Value of an Intensive and Structured Interval Practice Laparoscopic Training Course for Residents in Obstetrics and Gynecology: A Four-Year Prospective, Multi-Institutional Recruitment Study

OBJECTIVE To assess the educational value of an ongoing interval practice laparoscopy training program among obstetrics and gynecology residents. DESIGN Prospective cohort, multi-institutional recruitment study. We conducted structured laparoscopic training sessions for residents, using both inanimate and porcine models. The 6-day course was separated into two 3-day long modules conducted 2 months apart. A prospective evaluation of standardized tasks was performed using validated scales. Residents performance was compared using the Student t test and Wilcoxon signed-rank test when appropriate. SETTING International Center of Endoscopic Surgery (CICE), Clermont-Ferrand, France. PARTICIPANTS 191 PGY2 or PGY3 residents from different institutions. RESULTS Significant improvement in time and technical scores for both laparoscopic suturing and porcine nephrectomy was noted (p < 0.0001). After 2 months, we found no improvement in suturing time (p = 0.59) or technical scores (p = 0.62), and significant technical deterioration was observed for the right hand (p = 0.02). Porcine nephrectomy improvement remained significant after 2 months (p < 0.0001). CONCLUSIONS Despite significant short-term educational value of interval practice in laparoscopic performance, some acquired skills seem to deteriorate faster than anticipated.

Long-Term Follow-Up After Laparoscopic Management of Endometrial Cancer in the Obese: A Fifteen-Year Cohort Study

STUDY OBJECTIVE To assess the surgical outcomes and long-term results of laparoscopic treatment of endometrial cancer in obese patients, and compare these results with those of nonobese women. DESIGN Retrospective cohort study (Canadian Task Force classification II-2). SETTING Two referral cancer centers. PATIENTS Fifty-two obese and 155 nonobese women with clinical stage I endometrial cancer managed by laparoscopy from 1990-2005 in two referral centers. INTERVENTIONS Demographic, surgical, perioperative and pathological characteristics of obese women and nonobese women with endometrial cancer treated by laparoscopy were analyzed and then compared. Recurrence-free and overall survival was calculated by use of Kaplan-Meier method. MEASUREMENTS AND MAIN RESULTS Median BMI of the study population was 26.2 Kg/m(2). Median BMI among obese patients was 34.2 Kg/m(2). The conversion rate was independent from the BMI of the patient (3.8% vs 4.5%, p = .80). Neither mean operative time (187.5 vs 172 min, p = .11) neither hospital stay (5.2 vs 4.9 days, p = .44) were related with BMI. Lymphadenectomy was considered not feasible in 7 obese (17%) and 8 nonobese (7%) women (p = 0.09). Fewer lymph nodes were retrieved among obese women (8 versus 11, p <.0002). No differences were found between the groups in terms of perioperative complications. Median follow-up was 69 and 71 months for the obese and nonobese, respectively (p = .59). Overall and disease-free 5-year survival rates did not differ between obese and nonobese patients (90.3% and 87.5% versus 88.5% and 89.8%, respectively). CONCLUSION Despite some limitations, the laparoscopic approach seems to be particularly useful for obese patients with endometrial cancer, with similar survival and recurrence rates and without any more complications compared to the nonobese population.

Predictive factors of failure in management of ectopic pregnancy with single-dose methotrexate: a general population-based analysis from the Auvergne Register, France

In a general population setting, the existence of a learning curve for treatment of ectopic pregnancy with single-dose methotrexate has been demonstrated, because a significant decrease in failure rate can be achieved over time. Despite this finding, the risk of single-dose methotrexate failure increases significantly in patients with initial hCG levels>1,300 IU/L and/or in women who report having ever used combined oral contraception before pregnancy.