J.H. Ko

Safety of laparoscopically assisted vaginal hysterectomy for women with anterior wall adherence after cesarean section

Objective To evaluate the safety and surgical outcomes of laparoscopically assisted vaginal hysterectomy (LAVH) for women with anterior wall adherence after cesarean section. Methods We conducted a retrospective study of 328 women with prior cesarean section history who underwent LAVH from March 2003 to July 2013. The subjects were classified into two groups: group A, with anterior wall adherence (n=49); group B, without anterior wall adherence (n=279). We compared the demographic, clinical characteristics, and surgical outcomes of two groups. Results The median age and parity of the patients were 46 years (range, 34 to 70 years) and 2 (1 to 6). Patients with anterior wall adherence had longer operating times (175 vs. 130 minutes, P<0.05). There were no significant differences in age, parity, number of cesarean section, body mass index, specimen weight, postoperative change in hemoglobin concentration, or length of hospital stay between the two groups. There was one case from each group who sustained bladder laceration during the vaginal portion of the procedure, both repaired vaginally. There was no conversion to abdominal hysterectomy in either group. Conclusion LAVH is effective and safe for women with anterior wall adherence after cesarean section.

Feasibility and efficacy of laparoscopic restaging surgery for women with unexpected ovarian malignancy.

OBJECTIVE To evaluate the feasibility, surgical outcomes and complications of laparoscopic restaging surgery for women with unexpected ovarian malignancy. STUDY DESIGN We conducted a retrospective chart review of 14 women with unexpected ovarian malignancy who underwent laparoscopic restaging surgery including peritoneal washing cytology, laparoscopic pelvic and paraaortic lymphadenectomy up to the left renal vein level, omentectomy, and multiple peritoneal biopsies, and hysterectomy except three fertility saving surgery. RESULTS The median age and median body mass index women were 49 years (range, 22-63) and 24.2m/kg(2) (range, 18.9-25.3), respectively. The median operating time was 230min (range, 155-370). The median numbers of harvested pelvic and paraaortic lymph nodes were 26 (range, 6-41) and 18 (range, 2-40), respectively. The median return of bowel activity was 28h (range, 21-79). Four of the women were upstaged from the initial presumed stage. There were two intraoperative complications, laceration of the inferior vena cava and cisterna chyli rupture. There was one postoperative complication, port-site metastasis. There was no conversion to laparotomic surgery. The median follow-up period was 33 months. Thirteen of the patients have no evidence of recurrences, however one patient died after 22 months after the surgery. CONCLUSION Laparoscopic restaging surgery, performed by a specialized laparoscopic oncologist with sufficient laparoscopic experience and a well-trained operating team, is both feasible and effective in the management of unexpected ovarian malignancies.

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.