Kris Jardon

Laparoscopic management of adnexal masses: a gold standard?

PURPOSE OF REVIEWnTo review recent literature on the laparoscopic management of adnexal masses, when this approach may be considered as a gold standard.nnnRECENT FINDINGSnCyst rupture was recently demonstrated to be a significant prognostic factor in stage I invasive epithelial carcinoma, and it was recommended to restrict the laparoscopic approach to patients with preoperative evidence that the cyst was benign. The laparoscopic approach is still highly controversial in masses suspicious at ultrasound. The limits of the laparoscopic approach are discussed reviewing recent literature and our experience. The laparoscopic management of adnexal masses appears to be safe in most hospitals even in developing countries. This approach is being used with increasing frequency in unusual indications such as newborns, children, adolescents and pregnant women. The learning curve for endoscopic surgery appears to be longer than expected. Many patients with benign adnexal masses, such as ovarian endometrioma, are still treated by laparotomy or with an inadequate endoscopic technique. Several studies have suggested that the stripping technique is a tissue-sparing procedure.nnnSUMMARYnThe laparoscopic puncture of malignant ovarian tumours confined to the ovaries is uncommon, and should be avoided whenever possible. The teaching of endoscopy is essential to promote adequate procedures performed according to the principles of microsurgery and to preserve postoperative ovarian physiology.

Incidence of intraabdominal adhesions in a continuous series of 1000 laparoscopic procedures

OBJECTIVEnThe objective of the study was the laparoscopic evaluation of the incidence of intraabdominal adhesions related to prior abdominal surgery.nnnSTUDY DESIGNnThis was a prospective monocentric study including a continuous series of 1000 gynecologic laparoscopic procedures. Data were collected on history of abdominal surgery. A precise initial description of intraoperative adhesions was performed.nnnRESULTSnSix hundred thirty-seven of the 1000 procedures (63.7%) were performed in patients with a history of 1 or more than 1 abdominal surgery. Intraoperative adhesions were found in 211 of the 1000 subjects (21.10%). Fifty-nine of the 211 cases (28%) involved bowel loops. The prior indication for surgery did not seem to influence adhesion formation. The rate of intestinal adhesions significantly increased with the number of prior abdominal surgeries. The rate of intestinal adhesions was significantly higher in cases of prior midline incisions in comparison with the other incisions.nnnCONCLUSIONnExtensive preoperative knowledge of prior surgery is essential to evaluate the risk of adhesion formation.

Frozen Section in Laparoscopic Management of Macroscopically Suspicious Ovarian Masses

STUDY OBJECTIVEnTo study the usefulness of and applications for frozen section in the laparoscopic management of adnexal masses.nnnDESIGNnHistorical prospective study (Canadian Task Force classification II-3).nnnSETTINGnLarge tertiary care hospital with university affiliation.nnnPATIENTSnOne hundred forty-one women undergoing laparoscopy for a suspicious adnexal mass.nnnINTERVENTIONnAdnexal masses suspicious on ultrasound were managed by laparoscopy. After laparoscopic diagnosis, frozen sections were used to confirm a diagnosis of malignancy. Treatment was performed by laparoscopy whenever feasible.nnnMEASUREMENTS AND MAIN RESULTSnThe results of frozen section were compared with the results of permanent sections, and the consequences of the intraoperative diagnosis on the surgical management were evaluated. The frozen section diagnosis was correct in 125 of the 141 patients (88.7%). In one patient, the result was false negative. Specifically, frozen section diagnosis was correct in 96.8% of cases when a cyst or biopsy was sent for pathologic examination and in 86.4% when the whole adnexa was sent. It was correct in 93% of the cases involving tumors smaller than 100 mm and in 74% of larger tumors. It was correct in 92.3% of the women younger than 50 years and in 81.6% of women older than age 50. Intraoperative pathologic diagnosis was correct in 95.5% of benign tumors, 77.8% of low-malignancy tumors, and 75% of cancer cases.nnnCONCLUSIONnFrozen section is a useful examination for surgical management decision making; however, the limitations and the difficulties should be taken into account.

Total Laparoscopic Hysterectomy and Early Discharge: Satisfaction and Feasibility Study

STUDY OBJECTIVEnWhether, after laparoscopic hysterectomy (LH), selected patients may be safely and comfortably discharged on postoperative day 1 (day after surgery) using specific anesthesia and analgesia protocols that included Post Anesthetic Discharge Scoring System.nnnDESIGNnA prospective feasibility pilot study (Canadian Task Force classification II-3).nnnSETTINGnA French tertiary care hospital.nnnPATIENTSnA total of 35 patients who underwent total LH were selected using preestablished criteria based on age, surgical history, place of residence, and capacity to follow instructions.nnnINTERVENTIONSnAll patients had a telephone call the second and seventh day after surgery.nnnMEASUREMENTS AND MAIN RESULTSnOf 35 patients, 34 (97.1%) left the hospital the day after surgery. One patient was not discharged on surgeons instructions, because of technical difficulties during the procedure. Two patients (6.7%) required readmission because of complications. The first patient required hospitalization for vesicovaginal fistula at day 10 and had to undergo laparoscopic treatment of the fistula. The second consulted for hyperthermia at day 4 with suggestion of cuff cellulitis, and was discharged after 2 days of antibiotic treatment. Of 35 women, 34 (97.1%) were satisfied with the procedure and all would recommend it to other patients.nnnCONCLUSIONnUsing our protocol for analgesia, anesthesia, and early discharge (24 hours after surgery) may be safely proposed after total LH in selected patients. Satisfaction rate of patients on postoperative days 7 and 30 was very high.

Impact of intraperitoneal pressure of a CO2 pneumoperitoneum on the surgical peritoneal environment

BACKGROUNDnAnimal experiments have suggested that a high intraperitoneal pressure (IPP) might adversely affect the surgical peritoneal environment. The present experimental study investigates the impact of IPP of a CO(2) pneumoperitoneum on human peritoneum.nnnMETHODSnPatients undergoing laparoscopic surgery were subjected to either low (8 mmHg) or standard (12 mmHg) IPP. Normal peritoneum was collected from the parietal wall at the beginning of surgery and every 60 min thereafter. Expression levels of 168 genes that encode extracellular matrix proteins, adhesion molecules or inflammatory cytokine signaling molecules were measured in peritoneal tissues using real-time polymerase chain reaction (PCR)-based assay panels. Human peritoneal mesothelial cells (HPMCs) and human peritoneal fibroblasts (HPFBs) were incubated in a CO(2) insufflation chamber for 1 h at 12 or 8 mmHg. Hyaluronan (HA) synthesis and mRNA expression levels of hyaluronic acid synthases (HAS) and hyaluronidases (Hyal) in HPMCs and HPFBs were measured at 0, 4, 8, 12, 24 and 48 h after CO(2) gas exposure by ELISA and real-time PCR, respectively.nnnRESULTSnExpression levels of connective tissue growth factor (CTGF), matrix metalloproteinase-9, E-selectin, chemokine (C-X-C motif) ligand 2 (CXCL-2), Hyal-1 and Hyal-2 were significantly higher and those of HAS-1, HAS-3, thrombospondin-2 (TSP-2) and interleukin-10 were significantly lower in the 12 mmHg group compared with the 8 mmHg group. HA synthesis was significantly lower in the 12 mmHg group compared with the 8 mmHg group in HPMCs and HPFBs throughout the time course.nnnCONCLUSIONSnA low IPP (8 mmHg) may be better than the standard IPP (12 mmHg) to minimize the adverse impact on the surgical peritoneal environment during a CO(2) pneumoperitoneum.

Educational Value of an Intensive and Structured Interval Practice Laparoscopic Training Course for Residents in Obstetrics and Gynecology: A Four-Year Prospective, Multi-Institutional Recruitment Study

OBJECTIVEnTo assess the educational value of an ongoing interval practice laparoscopy training program among obstetrics and gynecology residents.nnnDESIGNnProspective cohort, multi-institutional recruitment study. We conducted structured laparoscopic training sessions for residents, using both inanimate and porcine models. The 6-day course was separated into two 3-day long modules conducted 2 months apart. A prospective evaluation of standardized tasks was performed using validated scales. Residents performance was compared using the Student t test and Wilcoxon signed-rank test when appropriate.nnnSETTINGnInternational Center of Endoscopic Surgery (CICE), Clermont-Ferrand, France.nnnPARTICIPANTSn191 PGY2 or PGY3 residents from different institutions.nnnRESULTSnSignificant improvement in time and technical scores for both laparoscopic suturing and porcine nephrectomy was noted (p < 0.0001). After 2 months, we found no improvement in suturing time (p = 0.59) or technical scores (p = 0.62), and significant technical deterioration was observed for the right hand (p = 0.02). Porcine nephrectomy improvement remained significant after 2 months (p < 0.0001).nnnCONCLUSIONSnDespite significant short-term educational value of interval practice in laparoscopic performance, some acquired skills seem to deteriorate faster than anticipated.

Comparison between standard and reverse laparoscopic techniques for rectovaginal endometriosis.

BackgroundThis study was designed to compare the surgical outcomes of standard and reverse laparoscopic techniques for the treatment of rectovaginal endometriosis.MethodsA retrospective study was conducted in a teaching and research hospital (tertiary center), which included 75 women subjected to laparoscopic treatment of rectovaginal endometriosis that required both vaginal resection and rectal surgery. Standard and reverse laparoscopic techniques were compared in 35 and 40 women, respectively. Student’s t test, Mann–Whitney test, and Fisher’s exact test were performed to compare groups when needed; pxa0<xa00.05 was considered statistically significant.ResultsThere was no statistically significant difference in operating time, blood loss, conversion rate, major intraoperative complications, length of hospital stay, and minor postoperative complications between the two techniques. The rate of major postoperative complications for the standard technique was 22.9%, whereas only 5% for the reverse technique (pxa0=xa00.02). The rate of postoperative rectovaginal fistula was the same for both techniques.ConclusionsMajor postoperative complications were reduced by using the reverse technique.

Long-Term Follow-Up After Laparoscopic Management of Endometrial Cancer in the Obese: A Fifteen-Year Cohort Study

STUDY OBJECTIVEnTo assess the surgical outcomes and long-term results of laparoscopic treatment of endometrial cancer in obese patients, and compare these results with those of nonobese women.nnnDESIGNnRetrospective cohort study (Canadian Task Force classification II-2).nnnSETTINGnTwo referral cancer centers.nnnPATIENTSnFifty-two obese and 155 nonobese women with clinical stage I endometrial cancer managed by laparoscopy from 1990-2005 in two referral centers.nnnINTERVENTIONSnDemographic, surgical, perioperative and pathological characteristics of obese women and nonobese women with endometrial cancer treated by laparoscopy were analyzed and then compared. Recurrence-free and overall survival was calculated by use of Kaplan-Meier method.nnnMEASUREMENTS AND MAIN RESULTSnMedian BMI of the study population was 26.2 Kg/m(2). Median BMI among obese patients was 34.2 Kg/m(2). The conversion rate was independent from the BMI of the patient (3.8% vs 4.5%, p = .80). Neither mean operative time (187.5 vs 172 min, p = .11) neither hospital stay (5.2 vs 4.9 days, p = .44) were related with BMI. Lymphadenectomy was considered not feasible in 7 obese (17%) and 8 nonobese (7%) women (p = 0.09). Fewer lymph nodes were retrieved among obese women (8 versus 11, p <.0002). No differences were found between the groups in terms of perioperative complications. Median follow-up was 69 and 71 months for the obese and nonobese, respectively (p = .59). Overall and disease-free 5-year survival rates did not differ between obese and nonobese patients (90.3% and 87.5% versus 88.5% and 89.8%, respectively).nnnCONCLUSIONnDespite some limitations, the laparoscopic approach seems to be particularly useful for obese patients with endometrial cancer, with similar survival and recurrence rates and without any more complications compared to the nonobese population.

Is laparoscopic hysterectomy feasible for uteri larger than 1000 g

OBJECTIVEnTo evaluate the feasibility of laparoscopic hysterectomy for uteri weighing more than 1000 g.nnnSTUDY DESIGNnA retrospective study was conducted in a tertiary center of laparoscopic surgery including 38 women submitted to hysterectomy for uteri weighing more than 1000 g. Patients submitted to open hysterectomy were compared to those submitted to laparoscopic hysterectomy. The primary statistical endpoint was the complication rate. Secondary endpoints were operating time, estimated blood loss, length of hospital stay, and conversion to laparotomy.nnnRESULTSnThe patients mean age was 49.4 years and mean BMI was 25.2 kg/m(2). The surgical intent was laparoscopic hysterectomy in 23 patients (60.5%) and laparotomy in 15 patients (39.5%). Conversion to open surgery was required in 4 patients (17.4%) due to inaccessibility of the pelvis at the beginning of surgery (n=2), technical difficulties during surgery (n=1), and intraoperative bleeding (n=1). One patient in the laparotomy group had an intraoperative ureteral injury. Despite longer operative time (130 vs. 80 min, p=0.002), laparoscopic surgery was associated with reduced length of hospital stay (3 vs. 6 days, p<0.001). Intraoperative bleeding was evaluated by the difference of pre- and post-operative hemoglobin and was equivalent in both groups (2.2 vs. 1.6g/dL; p=0.84). There was a tendency for more postoperative complications in the laparotomic group (33.4% vs. 8.7%; p=0.05).nnnCONCLUSIONnLaparoscopic hysterectomy is feasible for selected patients with uteri weighing more than 1000 g.

Impact of intraperitoneal pressure and duration of surgery on levels of tissue plasminogen activator and plasminogen activator inhibitor-1 mRNA in peritoneal tissues during laparoscopic surgery

BACKGROUNDnOur objective was to evaluate the impact of intraperitoneal pressure (IPP) and duration of a CO(2) pneumoperitoneum on the peritoneal fibrinolytic system during laparoscopic surgery.nnnMETHODSnHuman study: Patients undergoing laparoscopic surgery were divided into two groups: low (8 mmHg, n= 32) or standard (12 mmHg, n= 36) IPP. Normal peritoneum was collected from the parietal wall at the beginning of surgery and every 60 min thereafter. Mouse study: Mice were divided into three groups: low (2 mmHg) or high (8 mmHg) IPP or laparotomy. Peritoneal tissue was collected at 0, 4, 8, 24, 48 and 72 h, and 5 and 7 days after surgery. Real-time RT-PCR was performed in humans and mice to measure the levels of tissue plasminogen activator (tPA) and plasminogen activator inhibitor-1 (PAI-1) mRNA in peritoneal tissues.nnnRESULTSnHuman study: The tPA/PAI-1 mRNA ratio was significantly decreased in the 12 mmHg group at 1 h [P < 0.0001 versus matched initial peritoneal biopsies (MI)]. The tPA/PAI-1 mRNA ratio decreased in both groups at 2 h (P < .0.01 versus MI). Mouse study: The tPA/PAI-1 ratio was decreased at 0 h, and the difference was significant at 4 h in both the laparotomy (P < 0.001 versus controls, 0 h, 5 and 7 days) and high-IPP (P < 0.0001 versus 0, 48 and 72 h, 5 and 7 days) groups. No changes in tPA/PAI-1 ratio were observed in the low-IPP group.nnnCONCLUSIONSnA low IPP and shorter duration of surgery appear to minimally impact the fibrinolytic system during a CO₂ pneumoperitoneum.