Nicholas Kadar

Incisional hernias after major laparoscopic gynecologic procedures

OBJECTIVE: Our purpose was to determine the incidence of incisional hernias after operative laparoscopy. STUDY DESIGN: A retrospective case review was performed. RESULTS: The frequency of incisional hernias at extraumbilical 10 and 12 mm trocar insertion sites was one in 429 (0.23%) cases and five in 161 (3.1%) cases, respectively; the difference is statistically significant ( p = 0.007, Fishers exact test). Incisional hernias were also significantly more common if the fascia was left open ( p = 0.021), although three of the five hernias at 12 mm trocar sites occurred after attempted closure of the underlying fascia. CONCLUSION: The underlying fascia should be closed whenever a 10 mm or larger trocar is placed at an extraumbilical site during laparoscopy. The peritoneum may also require closure at 12 mm trocar sites if the trocar is placed through, rather than lateral to, the rectus sheath.

Positive peritoneal cytology is an adverse factor in endometrial carcinoma only if there is other evidence of extrauterine disease

The prognostic significance of peritoneal cytology among 269 women with clinical stage I and II carcinoma of the endometrium was studied. All patients were surgically staged and had undergone selective pelvic and para-aortic lymphadenectomies. Patients with clear cell and papillary serous carcinomas were excluded from the analysis. Thirty-four (12.6%) patients had malignant cells in the peritoneal washings (positive peritoneal cytology). The effect of positive peritoneal cytology on survival depended upon the extent of disease present. If the disease was confined to the uterus, positive peritoneal cytology did not influence survival; if the disease had spread to the adnexa, lymph nodes, or peritoneum, positive peritoneal cytology had a significant adverse effect on survival, decreasing it at 5 years from 73 to 13%, all recurrences being at distant sites. These findings suggest that treatment specifically directed at positive peritoneal cytology is not warranted unless extrauterine disease is present, and when it is, systemic rather than intra-abdominal treatment will be required to affect survival.

Laparoscopically assisted hysterectomy for uteri weighing 500 g or more

We attempted to determine the feasibility and results of laparoscopically assisted vaginal hysterectomy (LAVH) for removing symptomatic fibroid uteri not suitable for vaginal hysterectomy. We retrospectively reviewed cases in which the uterus weighed 500 g or more and was considered not suitable for traditional vaginal hysterectomy after examination under anesthesia. Laparoscopically assisted hysterectomy with or without unilateral or bilateral adnexectomy was successfully completed in 20 (91%) of 22 cases. Thirteen patients had concurrent laparoscopic lysis of adhesions, and one a laparoscopic bladder neck suspension. Mean uterine weight was 837 g, mean operating time 167 +/- 42 minutes, mean blood loss 390 +/- 107 ml, and mean hospital stay 2.6 days. No febrile morbidity or surgical complications occurred among these patients. The only significant intraoperative complication was bleeding requiring blood transfusions, which occurred in one of the two women who required abdominal hysterectomy. Our results suggest that LAVH is a safe and effective alternative to total abdominal hysterectomy of the very large fibroid uterus, and that conversion to total abdominal hysterectomy could be expected to occur in less than 10% of cases.

Preliminary prospective observations on the laparoscopic management of endometrial carcinoma using the two-stage approach to aortic lymphadenectomy

STUDY OBJECTIVE To determine the value of a two-stage approach to laparoscopic aortic lymphadenectomy (ALN) in women with endometrial cancer. DESIGN Prospective case series. PATIENTS Twenty-three consecutive, unselected women with endometrial cancer were managed prospectively according to a previously defined protocol. All had laparoscopic hysterectomy, ten required pelvic and one had an aortic lymphadenectomy (ALN). Pelvic lymph node metastases (PLNM) were present in two (20%) and aortic lymph node metastases in one (10%) patient. Mean age was 60; three women were over 80 years old, and two were 78 years old. Mean weight and body mass index were 192 and 33.5, respectively; two women weighed over 300 pounds and another two weighed over 250 pounds. Mean anesthetic time was 3.2 hours, mean blood loss 469 ccs, and mean drop in hemoglobin 2.5 g/dl. One patient was transfused. Median hospital stay was 2 days. One patient had a questionable ileus post-operatively, and another was hospitalized for 10 days to control her diabetes and blood pressure. CONCLUSIONS By predicating ALN on the presence of PLNM in endometrial cancer, the number of ALN can be reduced without reducing the number of aortic lymph node metastases detected, and laparoscopic management can be extended to morbidly obese women.

An operative technique for laparoscopic hysterectomy using a retroperitoneal approach.

The technique used for abdominal hysterectomy does not lend itself well to a laparoscopic approach because vital structures will be difficult to visualize and retroperitoneal spaces difficult to open. An entirely different approach is required. An operative technique for laparoscopic hysterectomy is based on a systematic dissection of the retroperitoneum in a very precise sequence of operative steps. It provides complete control of the operative field and allows visualization of all important retroperitoneal structures. The technique is simple to learn, and requires no special surgical skills beyond what is necessary for routine laparoscopic gynecologic procedures.

The electronic video operative laparoscope

A new 14-mm electronic video operative laparoscope accommodates a 5-mm operative channel. The video image sensor is located at the distal end of the laparoscope. The image quality is far superior to that of the standard video camera systems that attach to rigid endoscopes. Additional advantages are improved maneuverability, elimination of focusing, superior illumination system, and the capability to interchange with conventional video equipment. This instrument marks the next generation of laparoscopes.

A new technique of primary trocar insertion for laparoscopy.

A new method of primary trocar insertion exploits the anatomy of the anterior abdominal wall at the umbilicus. The point of fusion between the skin, fascia, and peritoneum is identified, and a tiny incision is made precisely over this point, enabling a small clamp to be introduced directly into the peritoneal cavity. After stretching the opening with this clamp, a 5-mm trocar is introduced into the peritoneal cavity over a blunt probe, and the abdomen is insufflated. The opening is stretched further with a Kelly clamp, and a 10-mm trocar is introduced over a blunt probe. The technique was used in 54 consecutive patients, 20 of whom had prior low vertical incisions. Ten women had very dense periumbilical adhesions, placing at least four at extremely high risk of bowel injury from blind entry. There were no injuries, and the technique is so quick and effective that it is now the authors routine method of trocar insertion for laparoscopy.