Cristiano Rossitto

Laparoendoscopic single-site surgery (LESS) for ovarian cyst enucleation: report of first 3 cases

OBJECTIVE To report the feasibility of ovarian cyst enucleation by using a laparoendoscopic single-site trocar through a transumbilical access. DESIGN Case reports. SETTING Teaching and research hospital. PATIENT(S) Three patients affected by large ovarian cysts. INTERVENTION(S) Enucleation of three large ovarian cysts by using a laparoendoscopic single-site approach with a new multiport trocar and standard laparoscopic instruments. MAIN OUTCOME MEASURE(S) Conversion to a multiaccess standard laparoscopic technique. RESULT(S) No conversion to multiaccess standard laparoscopic technique and no intraoperative or postoperative complications were observed. Mean operative time was 79.6 minutes. All patients were discharged home on day 1. CONCLUSION(S) Laparoendoscopic single-site enucleation of large ovarian cysts with ovary sparing is feasible with standard laparoscopic instruments, safe and effective, with good results in terms of cosmesis and postoperative pain. More clinical data are needed to confirm these advantages compared with standard laparoscopic technique.

A treatment selection protocol for recurrent ovarian cancer patients: the role of FDG-PET/CT and staging laparoscopy.

Objective: To investigate the best diagnostic and staging strategy for recurrent ovarian cancer. Methods: The negative predictive value, specificity, positive predictive value, sensitivity, and accuracy rates of the fluorine-18-fluorodeoxyglucose positive emission tomography computed tomography (FDG-PET/CT) and staging laparoscopy in identifying surgically treatable/untreatable patients are assessed in a consecutive series of 70 recurrent ovarian cancer cases. Moreover, the diagnostic performance of each staging procedure in the evaluation of the number of nodules is analyzed. Results: The negative predictive value of the FDG-PET/CT was 83.3%, whereas the positive predictive value was 76.9%. Specificity was 55.6%, whereas sensitivity was 93.0%. Accuracy rate was 78.6%. Negative predictive value, specificity, positive predictive value, sensitivity, and accuracy rate of staging laparoscopy were 88.9, 64.0, 80.8, 95.0 and 83.1%, respectively. Combined radiological and laparoscopic evaluation showed a negative predictive value of 88.9%, a specificity of 59.3%, a positive predictive value of 78.8%, a sensitivity of 95.3%, and an accuracy rate of 81.4%. The number of nodules identified by FDG-PET/CT corresponded in only 23 patients (40.3%) at laparotomy, whereas 15 of 30 patients were correctly diagnosed (50.0%) by staging laparoscopy. Conclusions: The combination of FDG-PET/CT and staging laparoscopy has a significant effect on the multimodal approach to the population of patients with recurrent ovarian cancer. Such techniques should be considered complementary, because of the potential of each one to identify a different setting of the disease.

A randomized study comparing the use of the Ligaclip with bipolar energy to prevent lymphocele during laparoscopic pelvic lymphadenectomy for gynecologic cancer

OBJECTIVE This prospective randomized pilot study compared the use of the Ligaclip (Ethicon Endo-Surgery, Cincinnati, OH) with bipolar coagulation in preventing lymphoceles after laparoscopic pelvic lymphadenectomy for gynecologic cancer. STUDY DESIGN Thirty patients with gynecologic malignancy, who had laparoscopic pelvic lymphadenectomy were randomly assigned for lymphadenectomy in 1 side of the pelvis using the Ligaclip, whereas, in the other side, the bipolar coagulation to seal lymphatic vessels was used. RESULTS At ultrasound examination, we detected lymphocele in 10 patients (33%). Lymphocele developed in 9 (30%) patients on the side where laparoscopic pelvic lymphadenectomy was perfomed using bipolar coagulation, and in 1 (3.3%) patient on the side where laparoscopic pelvic lymphadenectomy was performed using the Ligaclip. Univariate analysis revealed that the Ligaclips use compared with electrocoagulation in the laparoscopic pelvic lymphadenectomy is an independent predictive factor for development of lymphocele (P = .006). CONCLUSION This study demonstrates that the use of the Ligaclip to close lymphatic vessels may reduce the incidence of lymphoceles in patients undergoing laparoscopic pelvic lymphadenectomy.

Perioperative Outcomes of Laparoendoscopic Single-Site Surgery (LESS) Versus Conventional Laparoscopy for Adnexal Disease: A Case—Control Study

Objective: This study aimed to evaluate the potential advantages of laparoendoscopic single-site surgery (LESS) approach with respect to conventional laparoscopy. Methods: Thirty LESS patients were matched 2:1 with a previous cohort of 58 patients undergoing conventional laparoscopy for the same type of surgery (controls). Results: Median operative time (38.5 vs 54 minutes; P = .09) and estimated blood loss (20 vs 30 mL; P = .008) were more favorable in patients undergoing LESS treatment compared with those undergoing conventional laparoscopy. Rupture of the cyst was observed in 11 out of 30 cases (36.6%) and 26 of 58 controls (44.8%; P = .46). Median length of stay was 1 day in the cases and 2 in the controls (P = .03). Conclusions: Decreases in operative time, estimated blood loss, or length of stay should not be considered a benefit attributable to LESS; rather it seems there are no differences between these 2 surgical approaches after an adequate selection of patients.

Peritoneal carcinosis of ovarian origin.

Epithelial ovarian cancer (EOC) is the second most common genital malignancy in women and is the most lethal gynecological malignancy, with an estimated five-year survival rate of 39%. Despite efforts to develop an effective ovarian cancer screening method, 60% of patients still present with advanced disease. Comprehensive management using surgical cytoreduction to decrease the tumor load to a minimum, and intraperitoneal chemotherapy to eliminate microscopic disease on peritoneal surface, has the potential to greatly improve quality of life and to have an impact on survival in ovarian cancer patients. Despite achieving clinical remission after completion of initial treatment, most patients (60%) with advanced EOC will ultimately develop recurrent disease or show drug resistance; the eventual rate of curability is less than 30%. Given the poor outcome of women with advanced EOC, it is imperative to continue to explore novel therapies.

Laparoendoscopic Single-Site Surgery (LESS) for Treatment of Benign Adnexal Disease: Single-Center Experience Over 3-Years

STUDY OBJECTIVE To describe the effects of laparoendoscopic single-site (LESS) surgery performed over 3 consecutive years to treat adnexal disease and to report patient perioperative outcomes. DESIGN Retrospective clinical study (Canadian Task Force classification III). SETTING Tertiary care academic medical center. PATIENTS Women undergoing LESS because of a benign gynecologic indication, from January 2009 through December 2011. INTERVENTIONS Women with benign adnexal disease ≤10 cm underwent LESS surgery through a single 1.5- to 2.0-cm umbilical incision. Intraoperative and postoperative outcomes were carefully recorded, including the need for postoperative rescue analgesia. MEASUREMENTS AND MAIN RESULTS One hundred twenty-five patients were enrolled. Median patient age was 49 years, and median body mass index was 23. Surgical procedures included unilateral or bilateral salpingo-oophorectomy and unilateral or bilateral cyst enucleation. Median operative time was 48 minutes. Pain control was optimal, with an average visual analog score of 4/10. Both patients and surgeons were highly satisfied with the cosmetic result, and the cosmetic visual analog score was 9/10 at discharge and at 30 days after surgery. The number of women who underwent unilateral or bilateral salpingo-oophorectomy increased progressively and significantly yearly over the study period (16 vs 23 vs 40; p = .001). Median operative time for unilateral or bilateral salpingo-oophorectomy increased significantly from 2009 to 2010 and 2011 (34 vs 45 and 44 minutes; p = .001), together with median BMI (23 vs 23 vs 25; p = .04). CONCLUSION LESS is a desirable surgical approach in patients with simple adnexal disease.

Randomized Study Comparing Use of THUNDERBEAT Technology vs Standard Electrosurgery during Laparoscopic Radical Hysterectomy and Pelvic Lymphadenectomy for Gynecologic Cancer

STUDY OBJECTIVE To compare operative time with use of THUNDERBEAT (TB) vs standard electrosurgery (SES) during laparoscopic radical hysterectomy and pelvic lymphadenectomy to treat gynecologic tumors. DESIGN Evidence obtained from a properly designed, randomized, controlled trial (Canadian Task Force classification I). SETTING Gynecologic Oncology Unit of the Catholic University of the Sacred Heart in Rome, Italy. PATIENTS Fifty patients with early cervical cancer (FIGO stages IA2, IB1, IIA <2 cm) or locally advanced cervical cancer (FIGO stages IB2, IIA >2cm, IIB) who received neoadjuvant treatment (chemotherapy or radiochemotherapy) and demonstrated a complete or partial clinical response and early stage endometrioid endometrial cancer (FIGO stages IB, II) were randomly assigned to undergo TB (arm A) or SES (arm B). INTERVENTION Laparoscopic radical hysterectomy with bilateral pelvic lymphadenectomy, using an easily reproducible technique was performed. MEASUREMENTS AND MAIN RESULTS Fifty patients were available for analysis, with 25 women randomly assigned to TB (arm A) and 25 to SES (arm B). The median operative time was 85 minutes for TB vs 115 minutes for SES (p = .001). At multivariate analysis, endometrial cancer (p = .001) and TB (p = .001) were independently associated with shorter operating time. No differences in perioperative outcomes and postoperative complications were observed between the 2 arms. Patients who underwent TB reported less postoperative pain, both at rest (p = .005) and after the Valsalva maneuver (p = .008), with less additional analgesic therapy other than standard therapy required in patients who underwent SES (p = .02). CONCLUSION TB is associated with shorter operative time and less postoperative pain than is the standard technique (SES) in patients with uterine cancer.

Laparoendoscopic Single-Site Surgery for the Treatment of Benign Adnexal Disease: A Prospective Trial

Background. To validate feasibility, efficacy, and safeness of laparoscopic treatment of benign adnexal diseases through a single transumbilical access (LESS) in a prospective series of patients. Methods. A prospective clinical trial including 30 women has been conducted at the Division of Gynecology of Catholic University of Sacred Hearth of Rome. Patients underwent different laparoscopic procedures by LESS utilizing a multiport trocar and conventional straight laparoscopic instrumentation. Intra and perioperative outcome has been reported. Results. Ten mono/bilateral adnexectomies and 20 cystectomies have been performed by LESS approach. Laparoscopic procedures were completed through a single access in 28 cases (93.4%). No major intra- or postoperative complications were observed. Mean hospital stay was 1.3 days. Conclusions. LESS approach is feasible to treat benign adnexal disease with a very low conversion rate and no early or late complications. More clinical data are needed to confirm these advantages compared to standard laparoscopic technique.

Laparoscopic Myomectomy at 25 Weeks of Pregnancy: Case Report

We performed laparoscopic myomectomy for treatment of a large, twisted, subserous myoma at 25 weeks of pregnancy in a woman with acute abdominal pain that did not respond to analgesic therapy. There are few reports in literature about laparoscopic management of uterine leiomyoma during the first half of pregnancy that demonstrate its feasibility in selected cases. Laparoscopic myomectomy can be considered a minimally invasive alternative to the traditional laparotomy when myomectomy is necessary during the second half of pregnancy, resulting in less postoperative pain and shorter recovery time.

Laparoendoscopic Single-site Surgery for Fertility-sparing Staging of Border Line Ovarian Tumors: Initial Experience

Objective To report feasibility of laparoscopic fertility-sparing staging of border line ovarian tumors (BOTs) by using a laparoendoscopic single-site trocar through a unique transumbilical access. Study Design This study was conducted in our University Hospital. Four young patients, intended to be submitted to benign adnexal cysts enucleation by an innovative laparoendoscopic single-site approach using a multiport trocar inserted through a unique transumbilical access and straight laparoscopic devices, were found to be affected by border line ovarian tumor at intraoperative frozen analysis. Consequently patients were conservatively staged carrying out all the requested procedures in respect of oncologic guidelines and their child bearing desire, using same single-port access approach. Main outcome measures were conversion rate to multiaccess standard laparoscopic technique or to laparotomic approach and evaluation of intraoperative and postoperative-related complications. Results All the laparoscopic staging procedures were feasible through a single transumbilical access: no conversion to multiaccess standard laparoscopic technique nor laparotomy and no intraoperative or postoperative complications were observed. Mean operative time was 79 minutes. All patients were discharged home on day 1 with complete satisfaction toward cosmetic outcome. Final pathologic analysis confirmed stage FIGO 1A for all cases. The patients are free from recurrence at 10 months follow-up. Conclusions Laparoendoscopic single-site staging of border line ovarian tumors with preservation of fertility is feasible and effective with standard laparoscopic instruments. More clinical data are needed to confirm these advantages compared with standard multiaccess laparoscopic technique.