Joel M. Childers

Combined laparoscopic and vaginal surgery for the management of two cases of stage I endometrial cancer

Two postmenopausal patients with stage I adenocarcinoma of the endometrium who were managed with a combined laparoscopic and vaginal approach are presented. Surgical-pathologic staging was performed laparoscopically, with exploration of the abdomen and procurement of peritoneal cytology and pelvic and para-aortic lymph nodes. The adnexa were ligated and mobilized laparoscopically and removed with the vaginal hysterectomy. This approach offers decreased morbidity to the patient yet still obtains the same pathologic information and surgical goal as the traditional transabdominal approach.

The role of laparoscopic lymphadenectomy in the management of cervical carcinoma

Laparoscopic lymphadenectomy was performed on 18 patients with invasive carcinoma of the cervix prior to definitive radiation therapy and/or radical hysterectomy. Ten patients underwent pelvic and para-aortic lymphadenectomies prior to planned radiotherapy. Two of these patients had grossly positive pelvic nodes, and one had a microscopically positive para-aortic node. Eight patients with early disease were considered candidates for radical hysterectomy and underwent laparoscopic lymphadenectomy. Three of these patients were found to have positive pelvic lymph nodes and the hysterectomy was abandoned. Five patients underwent radical hysterectomies immediately following their laparoscopic procedures. The average number of lymph nodes removed laparoscopically in these patients was 31.4; the average number of additional lymph nodes resected at laparotomy with the radical hysterectomy was 2.8. A single microscopically positive parametrial lymph node was found on permanent section in 1 patient with radical hysterectomy. No significant complications were associated with the laparoscopic lymphadenectomies. Nine of the 13 patients who underwent laparoscopic procedures only were discharged on Postoperative Day 1. The ability to perform pelvic and para-aortic lymphadenectomy allows for complete surgical staging of carcinoma of the cervix laparoscopically.

HIGH-DOSE-RATE POSTOPERATIVE VAGINAL CUFF IRRADIATION ALONE FOR STAGE IB AND IC ENDOMETRIAL CANCER

PURPOSE To evaluate the effectiveness of postoperative high-dose-rate (HDR) vaginal cuff irradiation alone (1500 cGy in 3 fractions) in patients with Stage Ib and Ic endometrial cancer. METHODS AND MATERIALS This is a retrospective review of 102 patients with Stage Ib and Ic endometrial cancer treated with a hysterectomy and postoperative HDR intracavitary therapy alone during the period of 1/1/90-12/31/96. Each patient received 1500 cGy in 3 weekly treatments, dosed to a depth of 0.5 cm. Pathologic features such as depth of invasion, tumor grade, lower uterine segment (LUS) involvement, and lymphvascular invasion (LVI) were evaluated for their impact on recommended postoperative treatment. All survival curves were generated utilizing Kaplan-Meier methods and all statistical comparisons were via a Wilcoxon rank sum test. RESULTS The 5-year actuarial overall survival (OS) is 84% and the 5-year disease-free survival (DFS) is 93%. Locoregional disease control (pelvic control) was excellent with 97% of the patients free of pelvic disease at 5 years. Of the three pelvic failures only one was in the vaginal cuff. LVI, LUS involvement, Grade 3 and/or outer third myometrial involvement were identified in 41 patients. Thirty-one of these patients underwent a lymphadenectomy and there were two regional failures within this increased-risk group. CONCLUSIONS We obtained an excellent level of locoregional control with minimal morbidity and minimal time commitment for treatment with vaginal HDR brachytherapy alone. Our dose per fraction and total dose is lower than most reported series and there is no apparent loss in locoregional control. In addition, intermediate-risk patients and patients with an increased risk of recurrence (Grade 3, outer third myometrial involvement, LVI, LUS) may be treated with cuff irradiation alone, after surgical staging and a negative lymphadenectomy.

Ligation of the umbilical cord of an acardiac-acephalus twin with an endoscopic intrauterine technique

Background: Fetal acardia is a rare entity that complicates twin gestation. Reported survival of the normal or “pump” twin is below 50%. Perinatal mortality and morbidity typically result from heart failure in the pump twin caused by the circulatory demands of perfusion of the abnormal twin. Conservative management has not improved perinatal survival. Case: A 30‐year‐old woman with a twin gestation at 18 weeks was diagnosed with acardia acephalus. Congestive heart failure of the pump twin led to an intrauterine endoscopic attempt to ligate the umbilical cord of the acardiac twin. Both twins ultimately died. Conclusion: A variety of invasive techniques have been reported to accomplish occlusion of the acardiac twins umbilical cord, with inconsistent results. Maternal morbidity was minimal and technical success was achieved with an endoscopic intrauterine technique of umbilical cord ligation. Despite the poor fetal outcome in this case, endoscopic ligation of the acardiac twins umbilical cord should be considered for treating this unusual complication of twinning. (Obstet Gynecol 1993;82:708‐11)

Laparoscopic staging of the patient with incompletely staged early adenocarcinoma of the endometrium.

Objective: To determine the feasibility of laparoscopic staging in patients with presumed early stage but incompletely surgically staged adenocarcinoma of the endometrium. Methods: Thirteen patients with incompletely staged adenocarcinoma of the endometrium underwent laparoscopic staging. The women ranged in age from 36‐74 years (mean age 64) and weighed 132‐201 1b (mean 147.5). The interval between hysterectomy and laparoscopic staging ranged from 14‐63 days, for an average of 47. All patients underwent inspection of the entire intraperitoneal cavity, procurement of pelvic washings, and/or pelvic or para‐aortic lymphadenectomy, and two patients had remaining ovaries removed. Results: Extrauterine disease was found in three patients: One had intraperitoneal washings positive for adenocarcinoma, and two had pelvic lymph nodes positive for microscopic carcinoma. The average number of lymph nodes removed was 17.5. There were no intraoperative complications. Estimated blood loss averaged less than 50 mL, and the mean hospital stay was 1.5 days. Conclusion: Our initial experience indicates that this is a safe, effective procedure that offers a short hospital stay. We consider laparoscopic staging an attractive option for some patients with incompletely staged early adenocarcinoma of the endometrium. (Obstet Gynecol 1994;83:597‐600)

Transabdominal Cerclage: A Laparoscopic Approach

Background The placement of a transabdominal cervical cerclage has been regarded as considerably more morbid than a transvaginal cerclage, in part due to the need for two laparotomies. We describe a technique for the laparoscopic placement and removal of a transabdominal cerclage. Cases Two cases of women with insufficient cervical tissue to place a transvaginal cerclage were managed with a transabdominal cerclage. In one case, the cerclage was placed laparoscopically; in the other, the band was removed, facilitating uterine evacuation following the diagnosis of a missed abortion. In both cases a laparotomy was avoided. Conclusion Laparoscopic placement and removal of a transabdominal cerclage are promising options in the treatment of an incompetent cervix.

The role of laparoscopy in gynecologic oncology

The use of laparoscopy in the management of gynecologic malignancies has significantly increased over the last 5 years. The safety and adequacy of pelvic and para‐aortic lymphadenectomy has been established by several investigators. Patients with early carcinoma of the cervix are now undergoing Schauta (radical vaginal) hysterectomy after laparoscopic lymphadenectomy. Patients with carcinoma of the endometrium are treated by laparoscopically assisted vaginal hysterectomy in conjunction with laparoscopic pelvic and para‐aortic lymphadenectomy. Staging and second‐look procedures are now being performed laparoscopically in patients with carcinoma of the ovary.

Office laparoscopy and biopsy for evaluation of patients with intraperitoneal carcinomatosis using a new optical catheter

We report seven patients who underwent diagnostic laparoscopy and biopsy under local anesthesia using a new optical catheter. Six of these procedures were performed in the office. Four patients had previous malignancies (lung, breast, and fallopian tube), and intraperitoneal recurrences or new primaries were suspected. In two of these patients, laparoscopically directed biopsies confirmed adenocarcinoma similar to their prior malignancies, and in one a new primary was diagnosed. The fourth patient had no evidence of intraperitoneal disease. In the three patients with new intraperitoneal malignancies, biopsies obtained laparoscopically confirmed adenocarcinomas of the ovary in two patients and of the gastrointestinal tract in one patient. We feel that this procedure is a safe, simple, effective, and economical way to evaluate the intraperitoneal cavity and to obtain histologic or cytologic specimens for evaluation in patients with intraperitoneal malignancies. This is an ideal, minimally invasive method for detecting small-volume intraperitoneal disease. In addition, it allows some patients to be spared major operative procedures.

Preliminary Technique of Laparoscopic Extraperitoneal Infrarenal Paraaortic Lymphadenectomy in the Porcine Model

We developed an extraperitoneal approach to laparoscopic infrarenal paraaortic lymphadenectomy in the porcine model, with the ultimate aim of shortening the long learning curve of this procedure in humans. Surgery was performed on four females pigs with three 10-mm cannulas placed along the midaxillary line in prone position. The first and second pigs underwent subsequent laparotomy to evaluate the adequacy of lymph node dissection and complications. In all four animals, complete infrarenal paraaortic lymphadenectomy was successful, retrieving between 6 and 11 lymph nodes (average 9). Laparotomy in the first two animals confirmed adequate lymphadenectomy. No complications occurred. Operating time was shortened dramatically with each procedure (180, 120, 50, 40 min). In the porcine model this approach provides excellent exposure to the entire paraaortic lymphatic chain, is safe, and has a remarkably short learning curve. Development of a similar technique in humans may have significant advantages, including short learning curve, feasibility in obese patients and those with peritoneal adhesions, decreased adhesion formation, and reduced bowel complications associated with postoperative adjuvant irradiation. Further studies are indicated.

Laparoscopic para-aortic lymph node biopsy for diagnosis of a non-Hodgkin's lymphoma.

We present a case report of a 76-year-old male with non-Hodgkins lymphoma diagnosed by laparoscopic transperitoneal infrarenal para-aortic lymph node biopsy. This is the second report of the use of this technique in diagnosing a nonpelvic malignancy. The patient was discharged from the hospital in less than 24 h, during which complete histologic and immunochemical typing were performed. Laparoscopic biopsy offers significant advantages as an alternative to either fine-needle biopsy or open laparotomy.