Chien-Min Han

Hysterectomy by Transvaginal Natural Orifice Transluminal Endoscopic Surgery (NOTES): A Series of 137 Patients

STUDY OBJECTIVEnTo evaluate the feasibility and safety of hysterectomy in benign disease using transvaginal natural orifice transluminal endoscopic surgery (NOTES).nnnDESIGNnProspective observational study (Canadian Task Force classification II-3).nnnSETTINGnTertiary referral medical center.nnnPATIENTSnFrom May 2010 to August 2011, consecutive patients who were scheduled to undergo laparoscopic hysterectomy and without virginity or suspected pelvic inflammation or cul-de-sac obliteration were included.nnnINTERVENTIONnTotal hysterectomy via transvaginal NOTES.nnnMEASUREMENTS AND MAIN RESULTSnThe study included 137 patients, with mean (SEM) age 46.0 (0.4) years and body mass index 24.7 (0.4). Transvaginal NOTES was successfully performed in 130 patients (94.9%). Fifteen patients underwent concurrent adhesiolysis, and 17 underwent adnexal procedures. Mean (SEM) uterine weight was 450.0 (24.1) g; in 45 patients (34.6%), uterine weight was >500 g, and in 7 (5.4%) it was >1000 g. Operative time was 88.2 (4.1) minutes, with blood loss of 257.7 (23.9) mL. In 2 patients there was intraoperative hemorrhage or unintended cystotomy, and in another 5 transvaginal colpotomy failed because of a narrow vagina, cul-de-sac obliteration by bowel adhesions, or mass obstruction. Complications in these 7 patients (5.1%) were successfully managed via transabdominal laparoscopy. Five patients (3.6%) experienced postoperative urinary retention or febrile morbidity, and recovered uneventfully with conservative treatment.nnnCONCLUSIONnTransvaginal NOTES is a feasible technique for performance of hysterectomy and can be used in procedures that are difficult to complete via conventional vaginal surgery because posterior colpotomy is achievable. This procedure was not impeded by uterine volume, and had the advantage of no abdominal incision.

Comparison of the efficacy of the pulsed bipolar system and conventional electrosurgery in laparoscopic myomectomy – A retrospective matched control study

OBJECTIVEnComparing the safety and effectiveness of the pulsed bipolar (PK) system and conventional electrosurgery in laparoscopic myomectomy (LM).nnnMATERIALS AND METHODSnRetrospective chart review of 194 women with symptomatic uterine fibroids undertaken LM was performed. Cases of LMs with PK cutting forceps were compared with a matched control group of standard LMs with conventional electrosurgery. Outcome measures for both groups were studied comparatively in terms of the length of operative time, amount of blood loss, requirement of blood transfusion and length of hospital stay.nnnRESULTSnThe two groups were matched by age, body mass index, parity, previous cesarean delivery, size, number, and weight of fibroids. Amount of blood loss was significantly greater in electrosurgery group than in PK group at 243.8 ± 150.4mL versus 190.4 ± 178.5mL (p=0.025). Length of operation, hospitalization time, hemoglobin decrease, and requirement of blood transfusion were not significantly different.nnnCONCLUSIONnOur findings indicate that PK system is more effective in LM when compared with conventional electrosurgery. PK system has advantage over conventional electrosurgery in less blood loss and may offer an alternative option for patients undergoing LM.

Reducing peritoneal vascular endothelial growth factor concentration and inhibiting cancer scattering in a mouse model of laparoscopy

OBJECTIVEnThe objective of the study was to investigate the efficacy of early intraperitoneal (i.p.) paclitaxel administration in reducing vascular endothelial growth factor (VEGF) concentration in peritoneal fluid and preventing intraoperative cancer scattering during laparoscopy.nnnSTUDY DESIGNnNude mice were given i.p. ovarian cancer SKOV-3 xenografts to simulate intraoperative cancer dissemination and were assigned into concurrent- (day 0) and salvage-giving (day 5) treatment groups and nontreatment and nonxenografted groups.nnnRESULTSnThe xenografted nontreatment group showed markedly increased peritoneal VEGF concentrations, whereas the paclitaxel (no-tumor) control group showed significantly reduced concentrations. In mice with cancer xenografts, both concurrent- and salvage-giving treatment groups showed significantly decreased peritoneal VEGF concentrations (P < .05), and the concurrent-giving group had significantly fewer implanted cancer nodules (P < .05), whereas the salvage-giving group had decreased total tumor weights (P < .05) compared with nontreatment. Total tumor weights were found closely correlated to peritoneal VEGF concentrations in a positive exponential relationship (P = .003, R(2) = 0.581).nnnCONCLUSIONnEarly treatment with IP paclitaxel significantly decreased the VEGF concentration in peritoneal fluid, which was associated with reduced implantation and growth of disseminated cancer cells after laparoscopy. These encouraging results suggest a useful strategy for future clinical applications.

Accuracy of hysteroscopic biopsy, compared to dilation and curettage, as a predictor of final pathology in patients with endometrial cancer

OBJECTIVEnTo compare the methods of transcervical resectoscopy versus dilation and curettage (D&C) for endometrial biopsy and to compare these methods for the percentage of histological upgrades at the final posthysterectomy pathology findings in endometrial cancer.nnnMATERIALS AND METHODSnWe retrospectively reviewed 253 cases of uterine cancer diagnosed from May 1995 to January 2014. Included in the study were patients who received transcervical resectoscopy (TCR) or D&C biopsy as the diagnostic method and underwent laparoscopic staging at our institution. The International Federation of Gynecologists and Obstetricians (FIGO) grade in the pathological report of the biopsy and final hysterectomy were recorded. The extrauterine risk was stratified using the initial FIGO grade and depth of myometrium invasion. It was compared to the actual risk using final pathological findings.nnnRESULTSnWe identified 203 cases of endometrial cancer; 18 (8.9%) patients had a higher histological grade at the final hysterectomy. Among the 203 patients, 76 patients underwent TCR biopsy and 127 underwent D&C biopsy. The histological grade was upgraded in two (2.6%) patients in the TCR group. Three (3.9%) patients had positive peritoneal washings. In the D&C group, 16 (12.6%) patients with three (2.4%) positive peritoneal washings were upgraded.nnnCONCLUSIONnTranscervical resectoscopy could provide more precise grading information, compared to D&C (2.6% vs. 12.6%). Doctors could therefore make a more accurate staging plan, based on the preoperative risk evaluation.

Subtotal hysterectomy by natural orifice transluminal endoscopic surgery

Study objective: To introduce the innovative surgical procedure of treating benign uterine pathology with subtotal hysterectomy by natural orifice transluminal endoscopic surgery (NOTES). Design: Prospective observational study. Setting: Tertiary referral medical center. Methods: From June 2014 to May 2016, three patients with benign uterine diseases who were eligible for laparoscopic subtotal hysterectomy were recruited to undergo transvaginal NOTES at a tertiary referral medical center. Intraoperative and postoperative surgical outcomes were measured. Results: Subtotal hysterectomy by transvaginal NOTES was successfully completed in all patients without any conversion to conventional laparoscopy. The operative time was 144 ± 4.5 (138–149) minutes with an average estimated blood loss of 133 ± 62 (50–200) mL. None of the patients required an intraoperative blood transfusion. The mean specimen weight was 140 ± 59 (56–188) g. The final histology reports were uterine leiomyoma and adenomyosis in these three cases. There were no intraoperative or postoperative complications. No case required intraoperative or postoperative blood transfusion. No cases were converted to traditional laparoscopy or laparotomy. Conclusion: Our preliminary results showed the safety and feasibility of subtotal hysterectomy by transvaginal NOTES in selected patients. It is one of the most minimally invasive surgeries and results in invisible scars.

Natural orifice transluminal endoscopic surgery (NOTES) subtotal hysterectomy: A feasibility study

OBJECTIVEnHysterectomy via transvaginal natural orifice transluminal endoscopic surgery (NOTES) has been carried out for benign uterine diseases and nonprolapsed uteri in recent years. Subtotal hysterectomy was performed to remove the uterus with preservation of the cervix by abdominal, laparoscopic, or vaginal routes. The aim of this retrospective study is to gain insight into the feasibility and safety of subtotal hysterectomy through transvaginal NOTES.nnnMATERIALS AND METHODSnThis is the first case series study to describe the technique and to evaluate the feasibility of this innovative surgical procedure. 10 patients were recruited and underwent NOTES subtotal hysterectomy within one-year duration.nnnRESULTSnThe mean operative time was 106.7xa0±xa040.0xa0min with a mean blood loss of 250.0xa0±xa0120.2xa0mL. The mean weight of specimen retrieved was 452.2xa0±xa0227.8xa0g (range 195xa0g-905xa0g). None of these patients sustained injury to surrounding structures or major blood vessels during the surgery. Five patients required analgesia during the first 24xa0h post-surgery. Post-operative hospital stay ranged from 2 to 3 days. No patients complained of surgical complications at 1, 3, and 6 months follow-up. All patients recovered uneventfully and carried on daily activities without difficulty.nnnCONCLUSIONnThis study confirms the feasibility and safety of NOTES subtotal hysterectomy.