Pauline Chauvet

Comparison between resection, bipolar coagulation and Plasmajet®: A preliminary animal study

OBJECTIVE(S) To compare the most used types of surgical techniques, for peritoneal lesions management, to Plasmajet® (PJ), in term of healing and post-operative adhesion. STUDY DESIGN Prospective, experimental animal study. Female pigs (Landrace/Large White-Pietran) weighing 20-25kgs were used for the experiments. Eleven areas of 2cm2 were treated on each lateral side of the peritoneal wall. Two areas of control, 2 of surgical resection with scissors, 2 of bipolar coagulation, 2 of Plasmajet® 10 low (PJ10L, adjustment of the Plasmajet®) used in contact with the peritoneum, 2 of PJ10L used at 3-5mm from the peritoneum, 2 of PJ10L used at 10mm, 2 of PJ used at 10 High (PJ10H) close to the peritoneum, 2 of PJ10H used at 3-5mm, 2 of PJ10H used at 10mm, 2 of PJ used at 40 Low (PJ40L) used at 3-5mm, 2 of PJ40L used at 10mm from the peritoneum. RESULTS For each 2 areas, one was removed immediately for histological analysis. All animals were reoperated 14days later to evaluate macroscopic healing, adhesion score, histological inflammation and mesothelialization. Immediate histological analysis shows that in every treated area the peritoneum was completely vaporized, coagulated or removed. After resection, the healing was macroscopically perfect and there was no adhesion, as in the control area. After bipolar coagulation in half of cases there was adhesion. There was no adhesion after treatment by Plasmajet® 10 low used at 10mm from the peritoneum. CONCLUSION Surgical resection leads to perfect healing, and no adhesion formation. The use of Plasmajet® 10 low used at 10mm from the peritoneum could be an alternative to resection, because it allows complete superficial destruction, with a low rate of adhesion. Further study is required to explore and assess fully the potential of this device.

A System for Augmented Reality Guided Laparoscopic Tumour Resection with Quantitative Ex-vivo User Evaluation

Augmented Reality (AR) guidance systems are currently being developed to help laparoscopic surgeons locate hidden structures such as tumours and major vessels. This can be achieved by registering pre-operative 3D data such as CT or MRI with the laparoscope’s live video. For soft organs this is very challenging, and quantitative evaluation is both difficult and limited in the literature. It has been done previously by measuring registration accuracy using retrospective (non-live) data. However a performance evaluation of a real-time system in live use has not been presented. The clinical benefit has therefore not been measured. We describe an AR guidance system based on an existing one with several important improvements, that has been evaluated in an ex-vivo pre-clinical study for guiding tumour resections with porcine kidneys. The main improvement is a considerably better way to visually guide the surgeon, by showing them how to access the tumour with an incision tool. We call this Tool Access Visualisation. Performance was measured with the negative margin rate across 59 resected pseudo-tumours. This was 85.2% with AR guidance and 41.9% without, showing a very significant improvement (\(p=0.0010\), two-tailed Fisher’s exact test).

Laparoscopic extraperitoneal lumboaortic lymphadenectomy in 10 steps – Let's make it easier!

OBJECTIVE Laparoscopic extraperitoneal lymphadenectomy has both advantages of minimally invasive approach and retroperitoneal access. Although procedure is described for more than two decades there is a lack of diffusion of the technique. Standardization and simple description of the technique is main objective of this video. We described this procedure in 10 logical steps which could help to understand and perform this procedure. METHODS This video presents systematic approach to extraperitoneal lumboaortic lymphadenectomy which was clearly divided in ten steps ordered in a counter-clockwise direction. RESULTS CONCLUSIONS: Laparoscopic extraperitoneal access to lumboaortic lymph nodes is an effective method of lymphadenectomy which may bring benefits to a patient and physician. Presented ten steps help to perform each part of surgery in logical sequence making procedure ergonomic, easier to adopt and learn. Prior development of operative area in the extraperitoneal space followed by identification of anatomical landmarks is an important step which should precede lymph node dissection. Standardization of laparoscopic techniques could help to reduce learning curve.

Patient Quality of Life and Symptoms after Surgical Treatment for Endometriosis

STUDY OBJECTIVE To assess the impact of surgical treatment of endometriosis on quality of life and pain over a 3-year period of postoperative follow-up. DESIGN Prospective and multicenter cohort study (Canadian Task Force classification II-2). SETTING Five districts including a tertiary referral center and private and general public hospitals. PATIENT Patients (n = 981), aged 15 to 50years, underwent laparoscopic treatment (preferred approach) for endometriosis between January 2004 and December 2012. INTERVENTION Laparoscopic treatment for endometriosis. All revised American Fertility Society stages were included. MEASUREMENTS AND MAIN RESULTS The mean visual analog scale score for dysmenorrhea fell from 5.3 ± 3.7 (time 0) to 2.6 ± 3.3 at 6 months, and 2.3 ± 3.3 at 36 months of follow-up (p <.001). Mean visual analog scale scores for chronic pelvic pain and dyspareunia fell from 2.6 ± 3.5 and 2.7 ± 3.2, respectively, before surgery to 1.4 ± 2.5 and 1.1 ± 2.2 at 6 months and then 1.3 ± 2.5 and 1.2 ± 2.3 at 36 months of follow-up. The Short Form 36-Item survey analysis revealed the greatest increases linked to physical domains (i.e., bodily pain and role limitations) from 54.6 ± .9 and 63.3 ± 1.3, respectively, at time 0 to 74.4 ± .9 and 81.9 ± 1.1 at 6 months of follow-up (p <.001), with scores subsequently remaining stable. Among mental domains the most favorable results involved social functioning and role limitations due to emotional problems, which increased from 66 ± .8 and 65.7 ± 1.3 at time 0 to 75.6 ± .9 and 77.4 ± 1.3 at 6 months of follow-up, respectively (p <.001), with scores remaining stable over time. CONCLUSIONS Surgical treatment of endometriosis improves pelvic and sexual pain postoperatively in many women with endometriosis. Improvement later plateaus and remains stable, allowing patients to experience the beneficial effects over a period of years.

Use of indocyanine green in endometriosis surgery

OBJECTIVE To report and visually demonstrate the feasibility of using indocyanine green (ICG) in endometriosis surgery and to discuss potential benefits. DESIGN ICG fluorescent imaging has been validated to assess tissue perfusion with clinical use in many medical fields, including gynecology and digestive surgery, but has not described in endometriosis surgery for bowel assessment. To our knowledge, there is no validated, objective, intraoperative method to assess the vascularity of the operated bowel in endometriosis surgery, a potentially good indicator for postoperative fistula formation. Our center is conducting a registered clinical trial examining the use of ICG to evaluate the bowel vascularization after endometriosis rectal shaving surgery, and the potential role in reducing fistula rates (Institutional Review Board no 2016-002773-35). SETTING Tertiary university hospital. PATIENT(S) Three patients undergoing laparoscopic surgery for deep infiltrating endometriosis (DIE) with the use of a rectal shaving procedure. INTERVENTIONS(S) Patients undergoing laparoscopic surgery for DIE with a rectal shaving procedure were injected with ICG intravenously at the end of endometriosis resection. MAIN OUTCOME MEASURES Visual assessment of the rectal shaving area was assessed as fluoresced or not with the use of a Likert-type scale (0 = no fluorescence; 4 = very good fluorescence). RESULT(S) After ICG injection, all three patients have showed very good fluorescence levels at the rectal shaving area with no adverse reactions. Other uses of ICG are demonstrated throughout the video (vaginal cuff, ureter, and ovary assessment). CONCLUSION(S) ICG fluorescent imaging is feasible in endometriosis surgery, and there is an ongoing trial to determine if its use reduces postoperative fistula formation. CLINICAL TRIAL REGISTRATION NUMBER NCT03080558.

Lumbo-Aortic Lymph Nodes Dissection in Ten Steps.

We show the 10 essential steps for performing transperitoneal lumbo-aortic lymphadenectomy, from the peritoneal incision to the complete lymph nodes dissection, including the adequate exposure of the anatomic structures. An infrarenal lumbo-aortic lymphadenectomy is part of the staging and treatment of most of gynecologic malignancies. The lumbo-aortic lymphadenectomy can be divided into 4 areas: common iliac vessels and presacral nodes; lateroaortic nodes; inter-aorto-caval nodes; and latero-caval nodes. Good exposure and systematic surgery is needed to perform a complete lumbo-aortic lymphadenectomy. We performed a close technique for creating the pneumoperitoneum. A 10-mm trocar is inserted into the umbilicus, 5-mm trocars are placed in both iliac fossas, and a 10-mm trocar is placed in the suprapubic area. The camera is placed in the umbilical port Step 1: By relying on anatomical landmarks (the right ureter crossing the iliac bifurcation, promontory, and the aortic bifurcation), good exposure and the correct surgical planes of dissection can be found. Step 2: A horizontal peritoneal incision (until the left ureter) allows better exposition in many cases. This incision goes from the crossing point of the right ureter and the right external iliac artery to the left common iliac bifurcation. Step 3: Presacral and common iliac lymphadenectomy. Step 4: New position: the suspension of the peritoneum by T-lift devices is useful to achieve an adequate exposure of the surgical field, performing a peritoneum tent. The surgeon stands between the patient’s legs. Step 5: Creating the operative field under the tent: in this step, it is essential to separate lymph nodes and fat tissue from the mesenteric root and the peritoneum. Step 6: Identifying lateral landmarks: (i) right ureter and right ovarian vein: the dissection and section of the right ovarian vein must be done once it is identified, to avoid bleeding and complications; and (ii) left ureter and left ovarian vein. Once all your landmarks are identified, you can start the lymph nodes dissection. Step 7: Latero-aortic lymphadenectomy: the dissection must be carried out until the visualization of the left renal vein, taking special care visualize the junction between the hemiazygos vein and the renal vein. Step 8: Inter-aorto-caval lymphadenectomy: care must be taken with the right ovarian artery during this dissection.