Karicha Mairaing

Laparoscopic Dissection of Extensive Secondary Disseminated Peritoneal Leiomyomatosis

STUDY OBJECTIVE To demonstrate a minimal invasive surgical (MIS) technique for curative excision of extensive secondary disseminated peritoneal leiomyomatosis (DPL). DESIGN The Institutional Review Board of Human Investigation and Ethics Committee of Chang Gung Medical Foundation ruled that approval was not required for this study. PATIENT Woman aged 46 years. INTERVENTIONS, MEASUREMENTS, AND MAIN RESULTS In MIS the myoma has to be divided into small fragments for piecemeal retrieval through a small incision [1] with a widely used technique called morcellation (confined or unconfined) [2]. DPL is a rare sequellae after laparoscopic morcellation. Because this entity is rarely reported, this video demonstrates laparoscopic technique for safe removal of DPL post laparoscopic myomectomy and morcellation. A 46-year-old woman with a past history of laparoscopic myomectomy with specimen retrieval by a power morcellation 8 years ago presented with abdominal discomfort. Computed tomography revealed multiple iso-dense lesions in the uterine corpus and pelvic cavity. Upon laparoscopy multiple nodules were identified at the previous myomectomy scar, pelvic peritoneum, ovarian surface, and over the small bowel. A total laparoscopic hysterectomy with bilateral salpingo-oophorectomy along with excision of all visible lesions was performed. CONCLUSIONS In this video we demonstrate a safe retroperitoneal approach for complete excision of DPL. Laparoscopic hysterectomy or myomectomy with unconfined morcellation appears to be associated with the risk of DPL [3]. Complete tissue fragment retrieval will minimize the sequelae of morcellation. Hence, myoma remnants should be carefully extracted and confined morcellation should be considered. Because DPL causes significant distortion of pelvic anatomy, thorough knowledge of pelvic surgical anatomy and retroperitoneal approach for complete excision of all lesions is recommended.

Incidental finding of abnormal cervical pathology in hysterectomy specimens after normal preoperative Papanicolaou smears in Thammasat University Hospital.

BACKGROUND To investigate abnormal cervical histopathology (ACH) from hysterectomy specimens with normal preoperative Papanicolaou (Pap) smears. MATERIALS AND METHODS Medical records from May 2009 to April 2012 were retrospectively reviewed of subjects from whom hysterectomy specimens were taken in Thammasat University Hospital. All had normal preoperative Pap smears. ACH was the primary outcome. A p-value less than 0.05 was considered significant. A total of 483 subjects with an average age of 50.5 years were recruited. Benign cases of enlarged uterus and pelvic mass were present in 94% (430/483). Endometrial and ovarian cancer were found at 6.2 and 4.7%, respectively. In hysterectomy specimens there were 19 (4%) cases of ACH. Silent ACH with benign disease, endometrial and ovarian cancers were 1.2% (5/430), 33.3% (10/30) and 17.4% (4/23), respectively. The negative predictive value (NPV) and false negative rate of Pap smears were 96 and 4%, respectively. ACH in malignant cases were 27.9% (12/43) and 20% (2/10) in adequate (APS) and inadequate (IPS) Pap collection groups, respectively. ACH in benign condition were 0.68% (2/292) and 2.2% (3/138) in APS and IPS, respectively. ACH was more often found in hysterectomy specimens with indication of malignancy than benign conditions with statistical significance. One third of preoperative stage I endometrial cancer cases had cervical involvement. CONCLUSIONS Silent ACH in normal preoperative Pap smear was 4 %. Inadequate Pap smear collection is still the major problem in this study. Reducing inadequate Pap smear collection could reduce the false negative rate.