Norman Krause

Identification of the ureter and dissection of the bladder pillar in laparoscopic-assisted radical vaginal hysterectomy

Objective To determine the effect of tamoxifen on the endometrium in postmenopausal women with breast cancer and to try to identify, by pretreatment screening, subjects at higher risk of developing endometrial cancer. Methods Between January 1993 and January 1996, 264 postmenopausal women with breast cancer were studied prospectively with pelvic ultrasonography. Outpatient hysteroscopy and endometrial biopsy were done if ultrasound abnormalities were detected. Initial endometrial evaluation was done before treatment with tamoxifen was started, 20 mg daily, and annually thereafter. Attention was focused on endometrial lesions and, especially, endometrial hyperplasia, which was defined according to World Health Organization classification. Endometrial hyperplasia was subdivided into two broad categories: hyperplasia without cytological atypia and hyperplasia with cytological atypia. Adenocarcinoma in situ was defined as a well-differentiated endometrial carcinoma confined to the endometrial mucosa without myometrial invasion. Results Forty-six women (17.4%) had asymptomatic endometrial lesions diagnosed before starting tamoxifen, and two of these were atypical lesions. Patients with initial lesions and those without initial lesions were followed separately. At 3 years of follow-up, the incidence of atypical lesions was significantly higher in women with lesions initially than in those without (three lesions among nine women versus one lesion among 51 women, P = .009). Conclusion It appears that a group of high-risk subjects can be defined on the basis of endometrial evaluation before tamoxifen therapy; these women should be followed carefully because of the high incidence of severe atypical lesions.

Laparoscopy-assisted radical vaginal hysterectomy modified according to Schauta-Stoeckel.

In laparoscopy-assisted radical vaginal hysterectomy, laparoscopy is used to develop the paravesical and pararectal spaces. The cardinal ligament is isolated and cut after bipolar coagulation to the level of the deep uterine vein. By the vaginal approach, the ureters are identified before their entry into the bladder pillar. The uterine vessels are pulled down until their laparoscopically coagulated ends become visible. After incision of the vesicocervical reflection, the uterine fundus is grasped and developed (Döderlein maneuver). The lower cardinal and uterosacral ligaments are exposed by pulling the cervix and fundus uteri to the contralateral side. The cardinal and uterosacral ligaments are dissected and ligated, and the specimen is removed. We combined laparoscopic lymphadenectomy with radical vaginal hysterectomy in 33 women with cervical cancer. The mean operating time was 80 minutes for the vaginal phase and 215 minutes for the laparoscopic phase, including paraaortic and pelvic lymphadenectomy and preparation of the cardinal ligaments. Blood transfusions were necessary in four women. Three patients sustained injury to the bladder, one patient to the left ureter, and another patient to the left internal iliac vein. Repair was achieved at primary surgery for all intraoperative complications. No fistula was observed. The patients had fully recuperated after a mean of 28 days. The laparoscopy-assisted Schauta-Stoeckel approach may prove to be a safe alternative to conventional radical abdominal hysterectomy.

Establishing a new technique of laparoscopic pelvic and para-aortic lymphadenectomy☆

Objective To assess the number of operations necessary to develop and standardize a laparoscopic approach to pelvic and para-aortic lymphadenectomy, with radicality and number of complications as quality markers. Methods Over 4 years, 108 women had complete laparoscopic pelvic and para-aortic lymphadenectomies combined with laparoscopy-assisted radical vaginal hysterectomies for primary therapy of cervical cancer. Complete data and videotapes were available for 99 women. Operating time and radicality for specific anatomic subareas were measured by review of video documentation and histologic lymph node counts. Intra- and postoperative complications were recorded prospectively. To analyze the progress of surgery, we compared two groups of women, one operated on at the beginning of our study (early group, subjects 6–35) and one operated on in the final period of the study (late group, subjects 79–108). Results The operating time for pelvic and para-aortic lymphadenectomy increased constantly. Comparing the early and late groups for para-aortic lymphadenectomy, there was an increase in mean operating time (34.8 versus 73.2 minutes; P < .001) and mean histologic lymph node yield (5.1 versus 10.6; P < .001). For pelvic lymphadenectomy, mean operating time increased slightly (60.7 versus 69.7 minutes; not significant) but mean histologic lymph node count decreased over time (24.3 versus 21.0; not significant). Retrospective evaluation of videotapes showed that the radicality of lymphadenectomy improved continuously in all evaluated subareas. Conclusion Establishment of a protocol for para-aortic and pelvic lymphadenectomy took 100 operations. Video documentation was a more reliable indicator of progress in technical performance than were histologic lymph node counts.

Value of laparoscopic evaluation of paraaortic and pelvic lymph nodes for treatment of cervical cancer

OBJECTIVE Laparoscopy was used to identify and localize suspicious lymph nodes in patients with cervical cancer. STUDY DESIGN Eighty-four patients with cervical cancer International Federation of Gynecology and Obstetrics stage IA2 to IV were staged by laparoscopic paraaortic and pelvic lymphadenectomy. The accuracy of laparoscopic assessment of lymph node status was compared with the histologic result. Positive lymph nodes were localized topographically by use of laparoscopy. RESULTS Sensitivity and specificity of laparoscopic evaluation for identifying positive paraaortic and pelvic lymph nodes was 92.3%. Combination of laparoscopic evaluation and frozen section helped to diagnose all patients with involved lymph nodes correctly. In 13 of 84 (15.4%) patients the result of lymph node assessment by laparoscopic evaluation and frozen section changed primary therapy. In two of these patients one positive lymph node was located in the lateral part of the cardinal ligament, and the hysterectomy was extended to be a more radical procedure. CONCLUSIONS Laparoscopic evaluation identified the lymph node status in patients with cervical cancer with high accuracy. Topographic localization showed that the lateral part of the cardinal ligament is involved early in lymph node spread.

Laparoscopically assisted vaginal hysterectomy as an alternative to abdominal hysterectomy in patients with fibroids

Objective: Introduction of laparoscopically assisted vaginal hysterectomy (LAVH) was evaluated for its usefulness to replace abdominal hysterectomy in fibroids.Study design: A total of 240 women with a mean age of 46.7 years underwent hysterectomy over a period of one year. The technique of LAVH was introduced starting in the second quarter of the study period. Clinical data of 60 patients undergoing either LAVH or abdominal hysterectomy for fibroids were compared in a cross-sectional study by χ2 and t-test.Results: A comparison between the first and the last quarter of the study period showed that the rate of abdominal hysterectomies decreased from 66% to 12%, whereas LAVH increased from 0 to 40% (p<0.05). The rate of vaginal hysterectomies remained between 34% and 48%. Compared to abdominal hysterectomy, LAVH operating time was about 1/3 longer, hospital stay was shorter (3 days), and LAVH proved more cost-effective than abdominal hysterectomy (significance of all differences: p<0.05).Conclusions: LAVH is a valid alternative to abdominal hysterectomy in fibroids.

Left-sided laparoscopic para-aortic lymphadenectomy: anatomy of the ventral tributaries of the infrarenal vena cava.

OBJECTIVE We evaluated the anatomy of the infrarenal portion of the human inferior vena cava and their ventral tributaries by video laparoscopy. STUDY DESIGN A total of 112 patients underwent laparoscopic para-aortic lymphadenectomy for gynecologic malignancies. All procedures were videotaped. The number and anatomic distribution of the infrarenal tributaries of the anterior part of the inferior vena cava was evaluated retrospectively from videotapes. The inferior vena cava was divided into 3 levels: the area of the bifurcation of the vena cava (level 1), the area between the bifurcation and the inferior mesenteric artery (level 2), and the area between the inferior mesenteric artery and the right ovarian vein (level 3). RESULTS Tributaries were found in level 1 in 65 (58%) patients, in level 2 in 22 (19.6%) patients, and in level 3 in 1 (0.9%) patient; in 24 (21.5%) patients no tributaries were found. A total of 237 tributaries was counted: 82.3% (195 of 237) were located at level 1, 17.3% (41 of 237) at level 2, and 0.4% (1 of 237) at level 3. Patients with tributaries had a mean of 3 tributaries in level 1, a mean of 1.7 tributaries in level 2, and 1 patient had 1 tributary in level 3. CONCLUSIONS The ventral tributaries of the inferior vena cava show a specific distribution pattern. The knowledge of these anatomic landmarks can be important for laparoscopic surgeons to avoid accidental injury.

Laparoskopische paraaortale und pelvine Lymphonodektomie

ZusammenfassungLaparoskopische Verfahren zur Entfernung pelviner und paraaortaler Lymphknoten gewinnen in der gynäkologischen Onkologie zunehmend an Bedeutung. In der Hand von Spezialisten gehören diese endoskopischen Verfahren bereits zum operativen Standardrepertoire beim Staging und der Behandlung von malignen Tumoren der Cervix uteri, des Endometriums, des Ovars und der Vulva. Die bisher veröffentlichten Daten unterstreichen folgende potentiellen Vorteile der laparoskopischen Lymphonodektomie: Die Kombination von Vergrößerungseffekt durch Videolaparoskopie und elektrochirurgischer Technik erlaubt subtiles anatomisches Operieren mit geringem Blutverlust und hoher Radikalität; eine verlängerte Operationsdauer wird durch einen kürzeren stationären Aufenthalt kompensiert und die intra- und postoperative Komplikationsrate nimmt mit zunehmender Erfahrung signifikant ab. Bisher fehlen prospektiv randomisierte Studien, die einen validen Vergleich zwischen laparoskopischer und konventioneller Lymphonodektomie erlauben. In künftigen Untersuchungen muß vor allem gezeigt werden, daß die Heilungsrate nach endoskopischen Verfahren, der durch konventionelle Techniken erreichten gleichwertig oder überlegen ist.

Laparoscopic adnexal preservation in a patient with complete torsion--a case report.

OBJECTIVE Laparoscopic adnexal preservation in a patient with complete torsion. STUDY DESIGN Laparoscopy was performed in a 20-year-old nulliparous patient with a 24-h history of lower abdominal pain. RESULTS Torsion of the left adnexa was diagnosed and detorsion was performed. After detorsion the patient reported complete resolution of pain. At second look laparoscopy blood supply of the left adnexa was completely normalized and a cystadenofibroma was excised with preservation of the ovary. CONCLUSIONS Complete torsion of adnexa associated with edema and ischemia can be treated by laparoscopic detorsion.

Laparoskopische Verfahren zum Staging und zur Behandlung des Zervixkarzinoms

ZusammenfassungLaparoskopische Verfahren haben in den letzten Jahren zunehmend Bedeutung in der Diagnostik und Therapie des Zervixkarzinoms erlangt (Tabelle 1) [34]. So wird die laparoskopische pelvine und paraaortale Lymphonodektomie zur Beurteilung der Operabilität und zum Staging des Zervixkarzinoms eingesetzt. Bei primär operablen Tumoren wird die paraaortale und pelvine Lymphonodektomie laparoskopisch ausgeführt und bei negativen Lymphknoten und Fehlen einer intraabdominalen Metastasierung mit der laparoskopisch assistierten radikalen vaginalen Hysterektomie kombiniert. Werden durch Laparoskopie positive Lymphknoten gefunden, so kann ein Debulking durchgeführt und die Patientin der Strahlentherapie zugeführt werden. Zudem dienen laparoskopische Verfahren auch in Kombination mit der radikalen Trachelektomie beim frühinvasiven Zervixkarzinom der Erhaltung der Fertilität. Bei primär nicht operablen Tumoren kann die Laparoskopie dazu benutzt werden, Lymphknotenstatus und intraabdominale Tumorausbreitung zu beurteilen und Patientinnen in potentiell sekundär operabel und nicht operabel einzuteilen. Im weiteren kann bei primär untertherapierten Patientinnen, bei denen ein Zervixkarzinom im Hysterektomiepräparat als Zufallsbefund diagnostiziert wurde, eine Nachbehandlung mittels laparoskopischer Lymphonodektomie und laparoskopisch assistierter Kolpektomie erfolgen.SummaryLaparoscopic procedures have attained increasing importance in the diagnosis and therapy of carcinoma of the cervix in recent years (Table 1) [34]. Laparoscopic pelvic and para-aortal lymphadenectomies are therefore performed to assess the operability of carcinoma of the cervix and for its staging. In the case of primarily operable tumours, paraortal and pelvic lymphadenectomy is carried out by a laparoscopic procedure, and when the lymph nodes are negative nodes and there is no intra-abdominal metastasis the lymphadenectomy is combined with laparoscopically assisted vaginal hysterectomy. If laparoscopy discloses positive lymph nodes, debulking can be carried out and the patient can be referred for radiotherapy. In addition, laparoscopic procedures, even in combination with radical cervicectomy for early invasive carcinoma of the cervix, can mean conservation of the patients fertility. In the case of primarily inoperable tumours laparoscopy can be used to assess the lymph node status and the intra-abdominal tumour spread and to classify the patients condition as potentially secondarily operable or inoperable. In addition, in the case of primarily undertreated patients whose carcinoma of the cervix has been diagnosed incidentally in preparations of tissue examined following hysterectomy, posttreatment in the form of laparoscopic lymphadenectomy and laparoscopically assisted colpectomy can be performed.