In gynecologic oncology lymphadenectomy is of prognostic and
therapeutic importance because recurrence-free time and survival
depend on the metastatic involvement of lymph nodes.
Lymphadenectomies are not performed to such an extent as they are
indicated. This might be due to a laborious or problematic
preparation. The authors therefore report their experience in a
seldom taught preparation of the left para-aortic compartment in
the form of a learning curve.
MATERIALS AND METHODS: To access the left para-aortic area, the
descending colon is lifted to open the retroperitoneum along the
line of Toldt. The mesentery of the descending colon was separated
from the kidney along the fascia of Gerota by blunt preparation.
Time was measured from the incision of the peritoneum until the
renal vein was clearly visible.
RESULTS: The authors collected the data from the first 25
preparations. Mean duration for the left para-aortic preparation
was 7.8 minutes compared to 5.9 minutes for the right side.
Duration of preparation of the left area dropped from 11.0 minutes
within the first patients (#1 to #5) to 3.8 minutes in the last
patients (#20 to #25). No complications were observed in the study
group linked to the retromesenteric approach described.
CONCLUSION: Retromesenteric para-aortic lymphadenectomy is quick to
learn. The authors needed 20 preparations to observe a significant
drop in the time needed for preparation. Retromesenteric
para-aortic lymphadenectomy offers an excellent overview that
lightens lymphadenectomy and therefore reduces the risks for
PMID: 23327048 [PubMed – indexed for MEDLINE]
We present the case of an infertile woman with a giant myoma which
was laparoscopically removed. A 34-year-old patient was referred to
our department with a large abdominal mass. Ultrasound revealed an
18 cm uterine myoma. Diagnostic laparoscopy showed a giant uterine
myoma and with the help of a bent angle camera we started myoma
enucleation. The myoma was totally enucleated and removed without
disturbing the endometrial cavity. The uterine defect was closed
with an absorbable suture in two layers. The myoma was removed
using a PK (Gyrus) morcelator, without tissue or blood spillage in
the abdomen. The operation time was 165 minutes and the myoma’s
weight was 1,200 g. The patient recovered uneventfully.
Laparoscopic myomectomy can be an option even for giant myomas,
with the condition of an expert surgeon and appropriate surgical
instruments. PMID: 23724541 [PubMed – indexed for MEDLINE]
Treatment of Stage IB-IIA cervical carcinoma is controversial. The
choice to perform surgery or chemoradiation depends on the FIGO
Stage, which does not include evaluation of lymph node involvement,
although the prognosis of the patients depends on this evaluation.
There is no method however, to safely evaluate preoperative lymph
nodes metastasis, as both magnetic resonance imaging (MRI) and
computed tomography (CT) have poor sensitivity and high
specificity. As a result, inaccurate preoperative lymph node
assessment can lead to suboptimal treatment. The authors report the
case of a 42-year-old patient with cervical cancer Stage IB2, who
was primary treated with chemoradiation. Although at the time of
diagnosis no lymph node metastasis was detected, six months after
treatment, an enlarged five-cm lymph node was found in the area of
left iliac vein. The patient underwent laparoscopic pelvic and
para-aortic lymphadenectomy and nerve sparing radical hysterectomy.
Pathologic examination revealed one positive lymph node out of the
41 removed and no cancer cells in the uteral structures. There are
cases of cervical cancer in which chemoradiation seems to be
insufficient. Laparoscopic nerve-sparing radical hysterectomy can
be the treatment in patients with lymph node metastasis after
primary chemoradiation. It offers oncological safety combining the
advantages of laparoscopy and the nerve-sparing technique.
Furthermore, adjuvant chemotherapy or radiation can be initiated
immediately, offering the best therapeutical choice in the authors’
opinion. PMID: 24475590 [PubMed – indexed for MEDLINE]
OBJECTIVE: The radical hysterectomy type three can be accompanied
by postoperative morbidity, such as dysfunction of the lower
urinary tract with loss of bladder or rectum sensation. We describe
the technique of laparoscopic nerve-sparing radical hysterectomy
and patient’s outcome.
METHODS: Thirty-two patients underwent laparoscopic nerve-sparing
radical hysterectomy with pelvic lymphadenectomy. Both the
hypogastric and the splanchnic nerves were identified bilaterally
during pelvic lymphadenectomy.
RESULTS: The median age of the patients was 52 years, and the
average operating time was 221 min. There were no intraoperative or
postoperative complications considering the nerve-spring radical
hysterectomy. Postoperatively, in all patients spontaneous voiding
was possible on the third postoperative day with a median residual
urine volume of 50 ml.
CONCLUSIONS: Laparoscopic identification (neurolysis) of the
inferior hypogastric nerve and inferior hypogastric plexus is a
feasible procedure for trained laparoscopic surgeons who have a
good knowledge not only of the retroperitoneal anatomy but also of
the pelvic neuro-anatomy as this qualification could prohibit
long-term bladder and voiding dysfunction during nerve-sparing
Copyright © 2010 Elsevier Inc. All rights reserved.
PMID: 20701958 [PubMed – indexed for MEDLINE]
INTRODUCTION: The main objective of this study is to illustrate the
effectiveness and the safety of standardized technique of
laparoscopic lymphadenectomy (LNE), newly introduced in a
University Hospital, in patients with gynecologic malignancy.
MATERIALS AND METHODS: A cohort of 104 patients with gynaecologic
malignancies (71 with endometrial and 33 with cervical cancer), who
underwent laparoscopic pelvic with or without para-aortic LNE
between September 2008 and March 2010, were analyzed. Total
laparoscopic hysterectomy with bilateral salpingo-oophorectomy (TLH
& BSO) was the standard approach for patients with endometrial
cancer (n = 71), while laparoscopic (nerve sparing) radical
hysterectomy (n = 29), laparoscopic-assisted radical vaginal
hysterectomy (n = 2) and radical trachelectomy was the treatment
for patients with cervical cancer. All LNE were performed by a
learning team under the supervision of an expert surgeon, familiar
with the technique.
RESULTS: The median number of pelvic lymph nodes yielded was 22
(range 16-34) and of para-aortic 14 (range 12-24). The mean
operative time ± standard deviation for pelvic LNE for each side
was 29 ± 17 and 64 ± 29 min for para-aortic LNE. The overall
complication rate was 7.6% (n = 8). Two patients were reoperated
laparoscopically, one because of postoperative hemorrhage and the
other because of lymphocyst formation; laparoconversion was not
DISCUSSION: Laparoscopic lymphadenectomy performed by a learning
team with standardized technique is effective with adequate number
of harvested nodes, in acceptable operative time and with low rate
of perioperative complications.
PMID: 20607263 [PubMed – indexed for MEDLINE]
The present study analyzed the epidemiology and outcome of ectopic
pregnancy during a 9-year period on a total of 473 women. Our
follow-up shows that laparoscopic salpingostomy, performed in 84.9%
of the patients, is a safe and effective treatment for ectopic
Copyright © 2010 American Society for Reproductive Medicine.
Published by Elsevier Inc. All rights reserved.
PMID: 20605142 [PubMed – indexed for MEDLINE]
BACKGROUND: Endometriosis with bowel involvement is the most
invasive form and can cause infertility, chronic pelvic pain and
bowel symptoms. Effective surgical treatment of endometriosis
requires complete excision of endometriosis and in same case may
require segmental rectosigmoid resection.
METHODS: Between December 1997 and October 2003, 55 patients with
rectovaginal endometriosis underwent a combined laparoscopic
vaginal technique. 30 patients were found at a follow-up and
underwent a telephone interview. The questionnaire covered
questions about symptoms related to recurrences of intestinal
endometriosis, dyspareunia, dysmenorrhea and pregnancy.
RESULTS: Twenty-seven of 30 (90%) women have no clinical symptoms
of reported recurrence of endometriosis. Two patients (6.6%) had
evidence of recurrence of bowel endometriosis. Dysmenorrhoea
disappeared in 28 (93.3%), dyspareunia in 26 (86.7%) and pelvic
pain in 27 (90%) patients. 17 patients (31%) tried to become
pregnant and 11 of these patients (65%) became pregnant: 9 patients
delivered healthy newborns, 18 pregnancies occurred and 19 healthy
children were born.
CONCLUSIONS: Despite the small number of follow-up patients, our
94-month follow-up data demonstrated that endometriosis with bowel
involvement and radical resection was associated with significant
reductions in painful and dysfunctional symptoms, a low recurrence
rate (6.6%) and high pregnancy rate (36.6%).
PMID: 20458487 [PubMed – indexed for MEDLINE]
INTRODUCTION: Hysterectomy remains the most common major
gynecological operation. This is the first study that describes a
new technique of TLH without using any kind of uterine manipulator
or vaginal tube (TLHwM) and analyzes the intra- and postoperative
surgical outcome of the first 67 cases.
PATIENTS AND METHODS: Between October 2008 and December 2009, 67
patients underwent TLH without uterine manipulator or vaginal tube.
We analyzed the differences in the outcome by using three different
kinds of surgical instruments: in 21 cases the TLHwM was performed
using conventional 5 mm bipolar and scissors, in 22 cases using
Sonosurgical, and in 24 cases using PKS cutting forceps.
RESULTS: There was no intra- or postoperative complications. The
overall mean operating time was by TLHwM with salpingo-oophorectomy
98 min and without salpingo-oophorectomy, 80 min. The mean
operating time using cutting forceps was significantly lower. The
mean uterine weight was 263 g.
DISCUSSION: Uterine manipulator seems to be a safe and practical
surgical method, especially for patients with vaginal stenosis and
in cases of enlarged uterus. With its short operation time and no
complication rate, we believe that this method is an enrichment of
the laparoscopic hysterectomy techniques.
PMID: 20449598 [PubMed – indexed for MEDLINE]
Myomectomy is a common laparoscopic procedure and is often used in
patients with infertility, bleeding disorders and other symptoms
caused by leiomyomas. We present a case series report based on a
retrospective audit conducted from January 2001 up to December 2006
in our department. From 451 patients laparoscopically operated for
leiomyomas, we identified only 59 patients operated due to
infertility reasons. We report the post-operative rates of
pregnancy and mode of delivery after a median follow-up of 40
months post-operatively. Laparoscopic technique and obstetrical
outcome is discussed with recent literature review. The average
number of removed fibroids was 2. The mean weight of the leiomyomas
was 94.3 g. The cavum uteri was opened in eight patients. Overall,
42 out of 59 women delivered 51 live newborn babies, yielding a
post-operative success rate of 71%. The miscarriage rate
post-operatively was 8 out of 60 pregnancies (13%). In patients
with leiomyomas identified as infertility cofactor, laparoscopic
management is a convincing therapeutic approach. In our experience,
conception rate was 71%, and complications during pregnancy were
limited to 4% of the patients. Risk of uterine rupture during
labour was present in 4% of the cases, implying that mode of
delivery should always be discussed with the patient.