M. Canis

The learning curve of total laparoscopic hysterectomy: comparative analysis of 1647 cases.

STUDY OBJECTIVE To compare the frequency of complications of total laparoscopic hysterectomy performed in the first and more recent years of our experience, and based on that, offer ways to prevent them. DESIGN Retrospective, comparative study (Canadian Task Force classification II-2). SETTING University tertiary referral center for endoscopic surgery. PATIENTS During 1989-1995 and 1996-1999, 695 and 952 women, respectively, with benign pathology. INTERVENTION Total laparoscopic hysterectomy. MEASUREMENTS AND MAIN RESULTS No differences in patient characteristics were found between 1989-1995 and 1996-1999. Substantial decreases in major complication rates were noted, 5.6% and 1.3%, respectively. No major vessel injury occurred. Excessive hemorrhage (1.9%) and need for blood transfusion (2.2%) during the first period were statistically higher than in the second period (both 0.1%, p <0.005). Urinary complications (2.2%) including 10 bladder lacerations, 4 ureter injuries, and 1 vesicovaginal fistula occurred more frequently in the first period than in the second period (0.9%), when 6 bladder and 2 ureter lacerations and 1 vesicovaginal fistula occurred (p <0.005). One bowel injury and one bowel obstruction occurred in the first period, but no bowel complications in the second. Between periods, 33 (4.7%) and 8 (1.4%) conversions to laparotomy were necessary. During the first period there were nine reoperations; of six laparotomies, four were due to urinary injuries, one due to heavy vaginal bleeding, and one due to a vesicovaginal fistula; three diagnostic laparoscopies were required due to postoperative abdominal pain. Three reoperations during the second period were two laparoscopies due to heavy vaginal bleeding and one laparotomy due to a vesicovaginal fistula (p <0.005). Statistically significant differences in median (range) uterine weight 179.5 g (22-904 g) and 292.0 g (40-980 g) and operating times 115 minutes (40-270 min) and 90 minutes (40-180 min), respectively, were recorded (p <0.005). CONCLUSION Laparoscopic hysterectomy was safe, effective, and reproducible after training, and with current technique, had a low rate of complications.

Total Laparoscopic Hysterectomy for Very Enlarged Uteri

STUDY OBJECTIVE To evaluate short-term outcome of total laparoscopic hysterectomy (TLH) performed in women with very enlarged uteri. DESIGN Case control study (Canadian Task Force classification II-2). SETTING Hospital gynecologic service. PATIENTS Thirty-four consecutive women with very enlarged uteri. INTERVENTION Total laparoscopic hysterectomy for benign pathology. MEASUREMENTS AND MAIN RESULTS Women with uterine enlargement (group 1) were compared with 68 women with uteri weighing 300 g or less (group 2) who underwent TLH during the same period. Matching was based on patient age +/- 2 years, surgeon (experienced senior, fellow), whether or not Burch operation was performed, and whether or not adnexectomy was performed. The groups were compared for complication rates, operating time, hospital stay, change in perioperative hemoglobin concentration, and vaginal and laparoscopic uterine morcellation. They did not differ statistically significantly in terms of indications for surgery, parity, postmenopausal status, and preoperative hemoglobin levels. No difference was seen in complication rates between groups. Operating time was significantly shorter (p <0.001) in women with smaller uteri than in those with very enlarged uteri, 108 +/- 35 and 156 +/- 50 minutes, respectively. The groups did not differ significantly in day 1 hemoglobin level drop, analgesia requirement (oral, intravenous opioid), time to passing gas and stool, or hospital stay. No conversion to laparotomy was required in either group. CONCLUSION A very enlarged uterus should not be considered a contraindication for TLH. However, it may be necessary to undertake certain surgical steps to ensure optimal exposure of the operative field and more effective and safer excision of the uterine vascular pedicle.

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

BACKGROUND Animal 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. METHODS Patients 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. RESULTS Expression 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. CONCLUSIONS A 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.

5-aminolevulinic acid-induced (ALA) fluorescence for the laparoscopic diagnosis of peritoneal metastasis

Background: We performed a randomized experimental study in a rat model to evaluate the use of 5-aminolevulinic acid-induced (ALA) fluorescence in the laparoscopic diagnosis of peritoneal metastases of ovarian cancer. Methods: We injected 103 ovarian adenocarcinoma cells in the peritoneum of 31 rats. One week later, 5-aminolevulinic acid was injected in the peritoneum (100 mg/kg). After 3 h, we examined the rats using a 10-mm endoscope with a mono CCD camera and a light source developed for photodynamic diagnosis. Metastases on the parietal peritoneum were evaluated independently by two surgeons randomly assigned to use either a conventional light mode or the fluorescence mode. Results: The mean number of metastases detected was 2.84 with conventional laparoscopic light and 5.74 with ALA-induced fluorescence (p <0.0008). Metastases diagnosed by fluorescence were confirmed by pathologic examination. random peritoneal biopsy specimens taken from nonfluorescent areas were negative. conclusion: in this experiment, ala-induced fluorescence improved the detection of peritoneal metastases of ovarian cancer.

Computer-Assisted Laparoscopic myomectomy by augmenting the uterus with pre-operative MRI data

An active research objective in Computer Assisted Intervention (CAI) is to develop guidance systems to aid surgical teams in laparoscopic Minimal Invasive Surgery (MIS) using Augmented Reality (AR). This involves registering and fusing additional data from other modalities and overlaying it onto the laparoscopic video in realtime. We present the first AR-based image guidance system for assisted myoma localisation in uterine laparosurgery. This involves a framework for semi-automatically registering a pre-operative Magnetic Resonance Image (MRI) to the laparoscopic video with a deformable model. Although there has been several previous works involving other organs, this is the first to tackle the uterus. Furthermore, whereas previous works perform registration between one or two laparoscopic images (which come from a stereo laparoscope) we show how to solve the problem using many images (e.g. 20 or more), and show that this can dramatically improve registration. Also unlike previous works, we show how to integrate occluding contours as registration cues. These cues provide powerful registration constraints and should be used wherever possible. We present retrospective qualitative results on a patient with two myomas and quantitative semi-synthetic results. Our multi-image framework is quite general and could be adapted to improve registration in other organs with other modalities such as CT.

Elastic Shape Analysis of Cylindrical Surfaces for 3D/2D Registration in Endometrial Tissue Characterization

We study the problem of joint registration and deformation analysis of endometrial tissue using 3D magnetic resonance imaging (MRI) and 2D trans-vaginal ultrasound (TVUS) measurements. In addition to the different imaging techniques involved in the two modalities, this problem is complicated due to: 1) different patient pose during MRI and TVUS observations, 2) the 3D nature of MRI and 2D nature of TVUS measurements, 3) the unknown intersecting plane for TVUS in MRI volume, and 4) the potential deformation of endometrial tissue during TVUS measurement process. Focusing on the shape of the tissue, we use expert manual segmentation of its boundaries in the two modalities and apply, with modification, recent developments in shape analysis of parametric surfaces to this problem. First, we extend the 2D TVUS curves to generalized cylindrical surfaces through replication, and then we compare them with MRI surfaces using elastic shape analysis. This shape analysis provides a simultaneous registration (optimal reparameterization) and deformation (geodesic) between any two parametrized surfaces. Specifically, it provides optimal curves on MRI surfaces that match with the original TVUS curves. This framework results in an accurate quantification and localization of the deformable endometrial cells for radiologists, and growth characterization for gynecologists and obstetricians. We present experimental results using semi-synthetic data and real data from patients to illustrate these ideas.

Intérêt d’un enseignement structuré de la cœlioscopie en centre de simulation : enquête d’opinion auprès des internes

OBJECTIVE Assess residents satisfaction within their participation to a short and structured training to laparoscopy, gathering theoretical and practical issues. METHODS This course was divided in two periods of 3days including an individual prospective evaluation. For each period, the residents have answered to three questionnaires trying to evaluate their experience in laparoscopy and their short term and medium term satisfaction. RESULTS Three hundred residents from different French university hospitals have been involved in this study. After 4years, half of them were not satisfied with their chirurgical studies. Thirty-seven percent of them never attended to any surgical procedure as main operator. The training course has answered to their expectation for 95% of the residents and 85% said they now feel more confident about laparoscopy then before. According to 76% of them, it should be a compulsory and systematic training course and for 75%, they should be tested regarding their laparoscopy skills level during the resident studies period. The training on animals is the more efficient for 86% of them. CONCLUSIONS Due to the increasing number of residents and to the legal time for rest, the time spent in the operative room has decreased. People also do not accept easily the training made on true patients. Intensive and tested training are useful and answer to residents needs. They could be systematically integrated in their global curriculum.

Computer assisted Minimally Invasive Surgery: Is medical Computer Vision the answer to improving laparosurgery?

Minimally Invasive Surgery (MIS) is one of the most effective methods of modern surgical intervention that has considerable advantages compared with open surgery, including reduced trauma, pain, and post-operative recovery time. MIS has improved substantially over the years, chiefly due to new hardware innovations, including HD cameras and flexible head endoscopes. However, MIS continues to be hindered by several problems. In addition to hardware innovation, Computer Vision (CV) has been proposed as a way to overcome some of its current limitations. However, the research literature lacks a coherent picture of how the limitations can be best overcome by hardware, CV or a combination of the two. In this paper we focus on laparoscopic MIS, and list these limitations into 5 clear categories. We detail the effectiveness of hardware and CV solutions with respect to each limitation, from which we base the following hypothesis: CV is both complementary and necessary to hardware development, to overcome all 5 limitations in laparoscopy. Our paper is of value to laparoscopy surgeons, by conveying what is expected to be achieved in computer-aided laparoscopy over the next decade. It is also of value to medical CV researchers, by clarifying which problems are best solved with CV, in light of the hardware developments likely to occur over the next decade.

Realtime Wide-Baseline Registration of the Uterus in Laparoscopic Videos Using Multiple Texture Maps

We present a way to register the uterus in monocular laparoscopy in realtime using a novel two-phase approach. This differs significantly to SLAM, which is currently the leading approach for registration in MIS when scenes are approximately rigid. In the first phase we construct a 3D model of the uterus using dense SfM. This involves a method for semi-automatically masking the uterus from background structures in a set of reference frames, which we call Mask Bootstrapping from Motion (MBM). In the second phase the 3D model is registered to the live laparoscopic video using a novel wide-baseline approach that uses many texture maps to capture the real changes in appearance of the uterus. Capturing these changes means that registration can be performed reliably without needing temporal priors, which are needed in SLAM. This simplifies registration and leads to far fewer tuning parameters. We show that our approach significantly outperforms SLAM on an in vivo dataset comprising three human uteri.

Complication à long terme du morcellement utérin par voie cœlioscopique : les myomes parasitiques iatrogènes

OBJECTIVES Identify parasitic myomas following uterine laparoscopic morcellation and describe the circumstances of diagnosis, management, potential consequences and possible preventive measures. METHODS Retrospective study of observed cases in a university hospital between 2000 and 2012 and review of the literature. RESULTS Five cases were identified in our department. Pelvic pain was the main symptom in three patients while one was asymptomatic and one consulted for a cystocele. The average time to diagnosis was 88 months (3-192). Surgical removal was performed in four cases by laparoscopy and vaginally for one case. Histological examination showed typical leiomyomas, but in one case, an atypical leiomyoma with limited experience for a typical primary lesion. In the literature, there are about 50 cases. One required a bowel resection and for another one, after subtotal hysterectomy, histological examination showed complex atypical endometrial hyperplasia for normal endometrium initially. CONCLUSIONS This study should draw the attention of laparoscopic surgeon. It emphasizes, beyond a potential reoperation, a risk of atypical histological secondary processing. Surgical resection should be discussed even in case of asymptomatic lesions.