Laparoscopic Oophorectomy Research Articles

Comparison of pain and postoperative stress in dogs undergoing natural orifice transluminal endoscopic surgery, laparoscopic, and open oophorectomy

Few studies are available to compare the potential benefits of natural orifice transluminal endoscopic surgery (NOTES) approaches to traditional surgery. To compare complications, surgical stress, and postoperative pain. Prospective study in dogs. Research laboratory. Thirty dogs. Oophorectomy procedures were performed via NOTES and laparoscopic and traditional open surgery. Operative time, pain scores, systemic stress parameters (cortisol, glucose), surgical stress markers (interleukin 6, C-reactive protein), 3-day observation. Median operative times were 76, 44, and 35 minutes for the NOTES, laparoscopic, and open procedures, respectively, with the NOTES procedure being significantly longer than the other 2 procedures. All ovaries were completely excised, and all the animals survived without complications. The NOTES animals had greater increases in serum cortisol concentrations at 2 hours but no statistically significant differences in glucose concentrations compared with the other groups. Serum interleukin 6 and C-reactive protein concentrations were significantly increased at specific times compared with baseline in the NOTES group, but not in the open or laparoscopic surgery groups. Based on the cumulative pain score and nociceptive thresholds, the animals in the NOTES group demonstrated less evidence of pain. Small sample size, limited follow-up. Although the NOTES oophorectomy procedures took approximately twice as long and there may be more evidence of tissue damage as judged by increases in serum cortisol and interleukin 6 concentrations, the dogs in the NOTES group had lower pain scores, especially when compared with animals undergoing open surgery.

281 Laparoscopic oophorectomy: should it be considered in pre-menopausal women requiring aromatase inhibitors?

281 Laparoscopic oophorectomy: should it be considered in pre-menopausal women requiring aromatase inhibitors?

Surgical Treatment of Endometriosis in Private Practice: Cohort Study with Mean Follow-up of 3 Years

Study Objective To describe our experience with surgical treatment of endometriosis. Design Observational cohort study (Canadian Task Force classification II-2). Setting Private hospital. Patients One hundred sixty-three patients with histologically confirmed endometriosis who had completed a preoperative questionnaire, had available intraoperative findings and photographic documentation, and had been followed up to 6 years. Intervention Laparoscopic electrosurgical excision of endometriotic implants. Measurements and Main Results Patients completed a visual analogue scale (VAS) for 6 components of endometriosis-related symptoms. The EuroQol Group EQ-5D questionnaire was used for evaluation of quality of life. Long-term follow up was performed using a questionnaire and review of patient medical records. Mean (SD; 95% confidence interval) patient age at surgery was 31.01 (8.5; 29.7–32.3) years. The primary symptom at initial consultation was dysmenorrhea in 94 patients (57.67%, nonmenstrual pelvic pain in 44 (27%), dyspareunia in 11 (6.75%), menorrhagia in 8 (4.9%), infertility in 4 (2.45%), and pelvic mass in 2 (1.23%). Thirty-three patients (20%) had undergone previous surgery because of endometriosis. At surgery, endometriosis was stage I in 50 patients (30.67%), stage II in 65 (39.88%), stage III in 23 (14.11%), and stage IV in 25 (15.34%). Other surgical procedures performed with the index surgery were cystoscopy in 48 patients (29.45%), laparoscopic ovarian cystectomy in 24 (14.72%), laparoscopic hysterectomy in 15 (9.2%), laparoscopic appendectomy in 9 (5.5%), sigmoidoscopy in 6 (3.68%), laparoscopic oophorectomy in 6 (3.68%), extensive laparoscopic adhesiolysis in 5 (3.07%) bowel resection in 2 (1.25%), laparoscopic myomectomy in 1 (0.61%), and bladder resection in 1 (0.61%). Surgery proceeded to laparotomy in 6 patients (3.68%). Major surgical complications included bowel perforation, severe pelvic pain 1 week after laparoscopic excision, and temporary numbness of the right side of the perineum in 1 patient each. Minor postoperative complications included urinary tract infection in 3 patients and port site infections that resolved with oral antibiotic therapy in 2 patients. Follow-up was 37.82 (20.09; 34.74–40.92) months. Surgical excision of endometriosis had a positive effect on endometriosis-related symptoms. Four pain scores were reduced, with statistically significant differences (p <.001 and p <.05): dysmenorrhea, pelvic pain not related to menstruation, dyspareunia, and dyschezia. The positive effect of surgical excision on patient quality of life was demonstrated by a statistically significant difference on the EQ-5D index (p <.001) and the EQ-5D VAS (p <.001). Thirty-two (20%) patients underwent a second procedure after the index surgery. Endometriosis stage affects the probability of requiring further surgery because of recurrent symptoms. There was evidence of endometriosis at histologic analysis in only 13 (40.62%) patients who required further surgery. Conclusion Laparoscopic excision of endometriosis significantly reduces pain and improves quality of life as measured by both the EQ-5D index and the EQ-5D VAS, with a low complication rate.

Incisional Hernias after Laparoscopic Gynecologic Surgery: A Review of Six Cases

Study Objective: To determine the frequency of incisional hernias after laparoscopic gynecologic surgery. Design: Retrospective chart review of 2635 cases undergoing laparoscopic gynecologic surgery from 1993 to 2008. Setting: A practice and teaching hospital. Patients: Twenty six hundred thirty-five women with laparoscopic gynecologic surgery. Intervention: All patients underwent herinorrhaphy by laparotomy or by laparoscopy. Measurements and Main Results: A total of six incisional hernias through the laparoscopic trocar site were found over 16 years, a frequency of about 0.22%. Incisional hernias occurred following laparoscopic hysterectomy in three patients, laparoscopic myomectomy in one patient and laparoscopic oophorectomy in two patients. Small intestine herniated in five women and omentum herniated in one. The hernias appeared from 2 days to 10 days postoperatively. All women required surgery to retract the entrapped bowel or omentum and underwent herniorrhaphy by laparotomy (three cases) or by laparoscopy (three cases). Five occurred on left lower entry point in which the underlying fascia was not closed, suggesting that they were most likely related to the extensive procedures through this cannula. In one case of 91-year old woman, hernia occurred in umbilicus although the fascia defect was closed. Conclusion: To eliminate this complication, the underlying fascia should be carefully closed when extensive procedures are performed through a cannula port and when the women are old-aged.

Association between ovarian endometriosis and malignancy in the peri-menopausal period: report of two cases and review of the literature

The association of endometriosis and ovarian malignancy is about 1%, with a peak incidence in patients over 45 years. The best way of treating peri- and post-menopausal women with endometriosis is still a very controversial issue. We report two cases of peri-menopausal women in which endometriosis was associated to ovarian malignancy. The first case was a 49-year-old woman who underwent laparoscopic oophorectomy for an ovarian endometrioid cyst. Definitive histology showed ovarian endometrioid cyst with endometrioid and clear cell carcinoma. Subsequently, surgical restaging was performed. The other case was a 49-year-old woman who underwent hysterectomy and bilateral oophorectomy for an ovarian mass suggestive of endometriosis and uterine myomas. At frozen section examination, ovarian adenocarcinoma was found and staging procedure was performed. Definitive histology showed carcinosarcoma of the ovary with areas of endometriod adenocarcinoma. Given the non-infrequent association between ovarian endometriosis and cancer, more data are needed to decide for an aggressive or conservative approach to peri-menopausal endometriosis.

Development of human preantral follicles in vitro is enhanced by timed exposure to activin-A followed by FSH

OBJECTIVE: The aim of this study was to determine whether exposure to Activin-A followed by FSH would enhance growth and development of isolated human preantral follicles within a recently developed two-step serum free culture system.DESIGN: Ovarian cortical biopsies of approximately 5x4mm were obtained after informed consent during laparoscopic oophorectomy (n=2) and at caesarean section (n=1) from woman aged 40-41 years. Approval for this study was given by the local ethics committee.MATERIALS AND METHODS: Ovarian cortical strips containing primordial and primary follicles were cultured in serum free medium (McCoys + human serum albumen) for 6 days. At the end of this culture period secondary follicles were isolated from the strips. Intact secondary follicles with a mean diameter of 74 +/−5 microns (n = 33) were selected for further culture. Isolated follicles were placed individually within v shaped micro well culture plates in serum free medium in the presence of 100ng/ml of human recombinant activin A. After 2 days 50ng/ml of rhFSH in combination with 100ng/ml of activin A was added to approximately half of the cultured follicles (n=18) whilst the remainder (n=15) were exposed to only activin A for a further 2 days. Follicle diameters were measured on day 2 and day 4, cultured follicles at day 4 were fixed in Bouin's solution and prepared for histology and subsequent morphological analysis to determine oocyte and granulosa cell health.RESULTS: Isolated preantral follicles showed a significant increase in size during the first 2 days of culture in the presence of activin A. No follicular rupture or degeneration was observed during this period. Follicles exposed to FSH after 2 days in vitro showed a significantly higher increase in size (130+/−22 microns) when compared with those cultured in activin alone (91 +/− 13 microns) (p< 0.05). Morphological analysis showed an improvement in follicle health in those follicles exposed to both activin A and FSH.CONCLUSIONS: Primordial follicles can be activated to grow in vitro and develop to preantral follicles within 6 days of culture in cortical strips. Isolated preantral follicles show significant growth during a further 4 day culture period in the presence of activin A. Follicles exposed to a combination of activin A and FSH show a significantly greater rate of growth and improved morphology compared to activin alone. These preliminary results represent further progress towards achieving full in vitro growth of human oocytes. OBJECTIVE: The aim of this study was to determine whether exposure to Activin-A followed by FSH would enhance growth and development of isolated human preantral follicles within a recently developed two-step serum free culture system. DESIGN: Ovarian cortical biopsies of approximately 5x4mm were obtained after informed consent during laparoscopic oophorectomy (n=2) and at caesarean section (n=1) from woman aged 40-41 years. Approval for this study was given by the local ethics committee. MATERIALS AND METHODS: Ovarian cortical strips containing primordial and primary follicles were cultured in serum free medium (McCoys + human serum albumen) for 6 days. At the end of this culture period secondary follicles were isolated from the strips. Intact secondary follicles with a mean diameter of 74 +/−5 microns (n = 33) were selected for further culture. Isolated follicles were placed individually within v shaped micro well culture plates in serum free medium in the presence of 100ng/ml of human recombinant activin A. After 2 days 50ng/ml of rhFSH in combination with 100ng/ml of activin A was added to approximately half of the cultured follicles (n=18) whilst the remainder (n=15) were exposed to only activin A for a further 2 days. Follicle diameters were measured on day 2 and day 4, cultured follicles at day 4 were fixed in Bouin's solution and prepared for histology and subsequent morphological analysis to determine oocyte and granulosa cell health. RESULTS: Isolated preantral follicles showed a significant increase in size during the first 2 days of culture in the presence of activin A. No follicular rupture or degeneration was observed during this period. Follicles exposed to FSH after 2 days in vitro showed a significantly higher increase in size (130+/−22 microns) when compared with those cultured in activin alone (91 +/− 13 microns) (p< 0.05). Morphological analysis showed an improvement in follicle health in those follicles exposed to both activin A and FSH. CONCLUSIONS: Primordial follicles can be activated to grow in vitro and develop to preantral follicles within 6 days of culture in cortical strips. Isolated preantral follicles show significant growth during a further 4 day culture period in the presence of activin A. Follicles exposed to a combination of activin A and FSH show a significantly greater rate of growth and improved morphology compared to activin alone. These preliminary results represent further progress towards achieving full in vitro growth of human oocytes.

What is the Learning Curve for Robotic Assisted Gynecologic Surgery?

Study Objective The purpose of this study was to estimate the learning curve when using the da Vinci Surgical System (Intuitive Surgical Inc., Sunnyvale, CA) in benign gynecologic cases by a team of 2 gynecologic laparoscopists. Design Retrospective case series (Canadian Task Force classification II-1). Setting A private practice obstetrics/gynecology clinic. Patients Patients requiring major benign gynecologic surgery who were candidates for a laparoscopic approach. Intervention All patients who would have otherwise been offered a transabdominal or conventional laparoscopic procedure were offered the option of having their procedure performed laparoscopically with robotic assistance. Data that were collected included robot set-up times by the operative room staff, operative times for use of robot, total operative times, and perioperative outcome. We analyzed the learning curve defined as the number of cases required to stabilize operative time to perform the various procedures. Measurements and Main Results One hundred thirteen patients were treated over a 22-month period with the da Vinci Surgical System. Most procedures were hysterectomies, whereas other gynecologic procedures included supracervical hysterectomy, laparoscopic vaginal assisted hysterectomy, myomectomy, sacrocolpopexy, and oophorectomy. Total operative times for hysterectomies studied sequentially stabilized at approximately 95 minutes after 50 cases. The decrease in robotic time did not depend on uterine size. The mean length of hospital stay was 24 hours, and return to normal activities averaged 2.8 weeks. Conclusions Robotic assisted surgery is an enabling technology that allows gynecologic surgeons the ability to offer laparoscopic procedures to most of their patients. In the hands of surgeons with advanced laparoscopic skills, the learning curve to stabilize operative times for the various surgical procedures in women requiring benign gynecolologic interventions is 50 cases.

LAPAROSCOPIC OOPHORECTOMY IN THE MANAGEMENT OF BREAST DISEASE

Oophorectomy is being increasingly carried out in the management of breast disease, as either adjuvant treatment for breast cancer or for prevention of ovarian and fallopian tube cancer in BRCA gene mutation carriers. The aims of this study were to determine the surgical outcome of laparoscopic oophorectomy when carried out by breast surgeons and whether laparoscopic oophorectomy can be safely carried out during the same anaesthesia as breast surgery. Patients who had laparoscopic oophorectomy carried out by two breast surgeons were reviewed with regard to the indication, surgical outcome and concurrent procedures. Salpingectomy was also carried out when the indication was prevention. Seventy patients with breast disease had laparoscopic oophorectomy between January 2000 and June 2007. Forty-three patients had laparoscopic oophorectomy for adjuvant endocrine treatment of early breast cancer, 13 for prophylaxis, 7 for endocrine and prophylactic reasons and 7 for treatment of metastatic breast cancer. Sixteen patients had laparoscopic oophorectomy and breast surgery at the same time, without complication. Of note, four BRCA mutation carriers had prophylactic mastectomies, bilateral breast reconstruction and bilateral laparoscopic salpingo-oophorectomy. No patient required conversion to an open procedure, including 29 patients with previous abdominal surgery. There were no significant complications. Three patients had ovarian cancer or breast cancer detected in an ovary. Laparoscopic oophorectomy can be safely and efficiently carried out by breast surgeons with expertise in laparoscopic surgery. Previous abdominal surgery did not prevent a successful laparoscopic approach. Breast oncological and/or reconstructive surgery and laparoscopic oophorectomy can be reliably carried out as a combined procedure.

Ovarian Remnant Syndrome at the Port Site

Ovarian remnant syndrome is a rare gynecologic complication, mostly induced by difficult salpingo-oophorectomy with the residual ovarian tissue on the pelvic side wall. This is a report of a rare case of ovarian remnant syndrome at a port site after laparoscopic oophorectomy and a review of the related literature. A 22-year-old virgin had a laparoscopic oophorectomy for an endometrioma 5 years earlier. Postoperatively, she visited gynecologic clinics for a frequent painful sensation at the left port site. After sonographic examination and under the impression of a recurrent endometrioma, laparotomy and cyst excision were performed. Surprisingly, ectopic ovary was diagnosed by the pathologist. Review of the literature revealed ovarian remnant implantation at a port site as a very rare type of ovarian remnant syndrome. During laparoscopic oophorectomy in a woman without sexual exposure who is not a good candidate for culdotomy, the removal of the excised ovary through the port site is sometimes difficult and residual ovarian tissue implantation may occur. There are many methods to reduce the risk of port-site seeding, which we must keep in mind and execute to prevent such a complication.

Laparoscopic bilateral salpingo-oophorectomy as treatment for oestrogen dermatitis: a case report

We present a rare case of oestrogen dermatitis, which was successfully treated with laparoscopic bilateral oophorectomy. The mentality of medical and surgical treatment options is discussed.

Laparoscopic and Hand-Assisted Distal Pancreatectomy

With the increased use of CT, discovering incidental pancreatic lesions has become commonplace. Lesions in the distal pancreas lend themselves well to laparoscopic resection. We reviewed our experience with laparoscopic distal pancreatectomy. During the study period, 32 distal pancreatectomies were performed. There were 20 females. Mean patient age was 58.0 years (range, 23-83 years) and mean body mass index was 29.9 Kg/m2 (range, 19.9-44.7 Kg/m2). Technique was laparoscopic (25) or hand-assisted (seven) with one conversion in each group. The spleen was preserved in six patients (18.8%). Mean operative time overall was 238 minutes (range, 140-515 minutes); hand-assisted was 222 minutes and laparoscopic was 254 minutes. Estimated blood loss averaged 221 mL (range, 50-1800 mL). Mean tumor size was 2.7 cm (range, 0.6-7 cm). Tumor pathology was serous cystadenoma (10), neuroendocrine tumor (six), mucinous cystic neoplasm (four), intrapapillary mucinous neoplasm (four), adenocarcinoma (three), other (four), and solid pseudopapillary neoplasm (one). Mean length of stay was 5 days (range, 3-11 days). Complications were pancreatic fistula (six), wound infection (two), pulmonary embolism (one), pancreatitis (one), myocardial infarction (one), postoperative bleed from combined laparoscopic bilateral oophorectomy (one), and pancreatic stump staple line bleed requiring reoperation (one). There were no perioperative deaths. All pancreatic fistulas resolved with conservative management.

Medullary Thyroid Carcinoma Manifesting as an Ovarian Mass: Case Report and Review of Literature

To report the uncommon case of a woman with abdominal pain and a complex adnexal mass, who was subsequently found to have medullary thyroid carcinoma (MTC) metastatic to the ovary. We present the clinical history, physical findings, laboratory and imaging studies, and pathologic findings in a woman with metastatic MTC and locally aggressive disease. The genetic associations, variable clinical course, and histopathologic findings in MTC are reviewed. A 38-year-old woman with abdominal and pelvic pain underwent a computed tomographic scan of the abdomen, which showed a complex left adnexal mass. After laparoscopic left oophorectomy, histopathologic analysis of the resected ovary suggested the presence of a metastatic neuroendocrine tumor. The patient recovered but was referred to the surgery clinic 3 months later because of hoarseness, a left neck mass, and left-sided vocal cord paralysis. Further work-up was suggestive of MTC, which prompted RET testing for multiple endocrine neoplasia. The patient underwent left thyroid lobectomy and selective lymph node dissection but later required tracheostomy because of tumoral invasion of the trachea, laser debulking of the tumor, and external beam radiation therapy. One year postoperatively, development of a metastatic lesion in her right ovary necessitated a second oophorectomy. MTC usually manifests as a solitary thyroid nodule but should be considered in patients with metastatic lesions characterized by neuroendocrine features. This unusual case highlights the biologic and clinical variability of this often aggressive thyroid cancer, which necessitates an attentive work-up, a rigorous operative strategy, and a periodic postoperative surveillance program.

Six cases with borderline ovarian tumors diagnosed after laparoscopic cystectomy for benign ovarian tumors

Objective: The laparoscopic management of borderline ovarian tumors is controversial. We examined the outcomes of six cases with borderline ovarian tumors diagnosed after laparoscopic cystectomy for benign ovarian tumors.Methods: Among 127 patients who were treated by laparoscopic cystectomy for benign ovarian tumors between 1998 and 2006 at the University of the Ryukyus Hospital, 6 women were pathologically-diagnosed with borderline ovarian tumors. We retrospectively investigated the clinical outcomes of these patients.Results: The mean age was 42.5±23.3 years (range, 23-74 years), and the tumor size was 15.7±6.5 cm (range, 8.1-25.0 cm) . Laparoscopic cystectomy was performed in four cases who wished to preserve fertility. The remaining two postmenopausal women were treated by laparoscopic bilateral salpingo-oophorectomy. All six cases had stage Ic (b) tumor due to intraoperative tumor rupture (three mucinous, two serous, and one carcinoid) . All of the patients were surveyed without re-laparotomy for surgical staging or postoperative chemotherapy. Two of 4 women who desired pregnancy became pregnant within 1 year, and 3 recurrences as borderline tumors occurred in patients treated by laparoscopic cystectomy, 3, 14, and 21 months after the initial laparoscopic surgery. Two recurrent patients underwent laparoscopic oophorectomy, and the other recurrence was treated by salpingo-oophorectomy and lymph node sampling. The patients remained disease-free for 44, 27, and 56 months.Conclusions: Although long-term follow-up is indispensable, patients with borderline ovarian tumors can safely undergo conservative surgery.

Total Laparoscopic Hysterectomy for Female-to-Male Transsexuals

To compare the results of laparoscopic hysterectomy, salpingo-oophorectomy, and incidental appendectomy for female-to-male transsexuals with those of female patients. Retrospective chart abstraction of all patients undergoing total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, and appendectomy since September 1996. Significance from analysis of covariance or chi2 was set at .05. Five hundred ninety-three patients underwent total laparoscopic hysterectomy, oophorectomy, and appendectomy. Forty-one were identified as transsexual, 552 as females. The transsexuals were significantly younger (mean 32 years compared with 51 years, median 32 years compared with 49 years, P<.001), with lower parity (mean 0.05 pregnancies compared with 1.34 pregnancies, median 0 pregnancies compared with 1 pregnancy, P<.001), yet had similar body mass index and height. Transsexuals' surgeries had shorter operating times (mean 74 minutes compared with 120 minutes, median 57.5 minutes compared with 116 minutes, P<.001), with less blood loss (mean 27 mL compared with 107 mL, median 20 mL compared with 50 mL, P<.001) and lower uterine weight (mean 118 g compared with 167 g, median 89 g compared with 140.5 g, P<.001). The total complication rates (12.2% compared with 8.3%), as well as the reoperative complication rates (4.9% compared with 4.3%) were not significantly different. Total laparoscopic hysterectomy offers appropriate surgical outcomes for those patients identifying themselves as transsexual.

Feasibility of endoscopic transgastric distal pancreatectomy in a porcine animal model

In contrast to laparoscopic tubal ligation, oophorectomy, and appendectomy, laparoscopic distal pancreatectomy is associated with a morbidity rate of more than 50% and a mortality rate of more than 3%. To develop a minimally invasive, transgastric endoscopic technique for distal pancreatectomy in a nonsurvival series in swine. Experimental study. Animal trial at a tertiary-care academic hospital. Six healthy Yorkshire swine under general anesthesia. A double-channel gastroscope was introduced into the stomach, and a gastric incision was created by using a triple-lumen, 4-mm, cutting-wire needle knife. The peritoneal cavity was accessed. An Endoloop was placed endoscopically around the distal aspect of the pancreas, and the tail of the pancreas was transected by using a diathermic snare. One to 3 hemoclips were placed across the pancreatic duct. The pancreatic specimen was retrieved, and the gastrotomy was closed endoscopically with metal clips. The animals were euthanized after the procedure. The abdominal cavity was examined grossly, and the resected pancreas was examined histologically. Feasibility of endoscopic transgastric distal pancreatectomy and rate of complications. The pancreatic tail was successfully resected via a transgastric endoscopic approach in all animals. The procedure took an average (standard deviation) of 77.3 +/- 18.9 minutes. There was 1 complication, an episode of bleeding from a splenic laceration, which resulted in the loss of 250 mL of blood. Nonsurvival series, animal study. Transgastric endoscopic distal pancreatectomy is technically feasible and can be performed in the porcine animal model.

Benign Struma Ovarii in a Patient With Invasive Papillary Thyroid Cancer: Detection with I-131 SPECT-CT

Abstract: A 78-year-old woman was referred for I-131 therapy following total thyroidectomy for invasive papillary thyroid cancer. The thyroglobulin titer was markedly elevated following thyroxine withdrawal, and she was given 5,550 MBq (150 mCi) of I-131 following additional pretreatment with rTSH (Thyrogen). A posttherapy scan showed intense, focal activity in the pelvis, which localized to the right ovary on SPECT-CT fusion examination. Contrast CT confirmed a cystic right ovarian tumor and she underwent laparoscopic oophorectomy, which revealed a benign follicular thyroid adenoma (struma ovarii). At 6-month follow-up, a whole body iodine scan was normal, and the TSH-stimulated thyroglobulin was undetectable.

Laparoscopic Prophylactic Oophorectomy Plus N3 Lymphadenectomy for Advanced Rectosigmoid Cancer

The primary aim of the present retrospective study was to evaluate the feasibility and efficacy of laparoscopic prophylactic oophorectomy plus N3 lymph node dissection for patients with rectosigmoid cancer. The secondary aim was to explore the clinicopathologic features of ovarian micrometastasis from rectosigmoid cancer. We performed 244 laparoscopic resections of rectosigmoid cancer in women during a 6-year period. In them, 34 patients (13.9%) were subjected to prophylactic oophorectomy plus N3 lymphadenectomy in addition to the standard anterior or low anterior resection of rectosigmoid cancer, because the patients presented with ovarian cystic lesions, tethering of the ovary to the primary rectosigmoid tumor, and/or pelvic ascites accumulation, which were postulated as the indicative findings for the synchronous ovarian micrometastasis. The surgical procedures are detailed in the attached video. The surgical outcomes were compared between patients with (n = 34) and without (n = 210) these two additional procedures. In analyzing the clinicopathologic features of ovarian micrometastasis, we included both cases of laparoscopic (n = 34) and traditional open surgery (n = 30), whose prophylactic oophorectomy was performed by the same surgical indications. Although the operation time was significantly longer (264.2 +/- 24.5 vs. 192.5 +/- 24.2 minutes, P < .0001) in patients with prophylactic oophorectomy and N3 lymphadenectomy, there was no significant difference between patients with and without the two additional procedures in blood loss, wound length, postoperative complications, diverting ileostomy, and mortality. Although flatus passage, hospitalization, postoperative pain, and return to partial activity were statistically different between the study groups, they were deemed clinically unimportant because the difference of mean was very small. Foley removal was delayed in patients with N3 lymphadenectomy by 2 days. With respect to surgical efficacy, we found that patients undergoing the two additional procedures could collect significantly more lymph nodes (22.0 +/- 4.0 vs. 14.4 +/- 2.4, P < .0001) for pathologic staging and facilitated upstaging of nodal status in three patients (8.8%). Patients undergoing prophylactic oophorectomy plus N3 lymphadenectomy could achieve good oncologic outcome, with the estimated 5-year survival rate of 62.5% and 69.2% in patients with and without ovarian micrometastasis, respectively. Clinicopathologically, patients with ovarian micrometastasis (n = 15) tended to have vascular invasion of tumor cells, as compared with those without (n = 49). However, ovarian micrometastasis was not related to menstrual status of patients, tumor location, tumor size, morphology, differentiation, mucin production, T stage, nodal invasion, and level of carcinoembryonic antigen. Laparoscopic surgical techniques could be safely applied to perform prophylactic oophorectomy plus N3 lymphadenectomy with acceptable efficacy in a highly selected subset of patients with rectosigmoid cancer.

The feasibility and efficacy of laparoscopic oophorectomy in the management of pelvic pain after hysterectomy

SummaryWe aim to assess the feasibility and efficacy of laparoscopic oophorectomy in women with pelvic pain after hysterectomy in this retrospective review of 35 consecutive women presenting with pelvic pain who had had their ovaries conserved at the time of hysterectomy. Pain was attributed to the presence of these residual ovaries if there was an adnexal mass – or the pain improved following ovarian suppression with a GnRH analogue. The procedure was completed laparoscopically in 32 (91%) women. Overall, 27 (77%) women reported symptomatic relief following surgery. We conclude that laparoscopic oophorectomy is safe and provides symptomatic relief in this group of women.

Clinical Experience with Recombinant Activated Factor VII in a Surgical Patient with Coagulation Factor VII Deficiency - A case report -

A 33-yr old female patient with coagulation factor VII deficiency was scheduled for laparoscopic oophorectomy under the diagnosis of ovarian teratoma. Plasma concentration of factor VII of this patient was 9 IU/dl (normal range; 60-140 IU/dl) and the prothrombin time INR (International Normalization Ratio) was 1.79 (normal range; 0.8-1.2) on the day before the operation. Total 1,200μg (30μg/kg) of recombinant activated factor VII (rFVIIa) was administered just before the start of the laparoscopic procedure, which was accomplished safely without severe hemorrhage or other complications. Postoperative course was uneventful. In addition, this article provides the clinical implication of rFVIIa in terms of hemostasis management in hemophiliacs and surgical patients.

Laparoscopic Ureteroneocystostomy with Vesicopsoas Hitch: Nonrefluxing Ureteral Reimplantation Using Cystoscopy-Assisted Submucosal Tunneling

We described laparoscopic nonrefluxing ureteral reimplantation with a psoas hitch using a submucosal tunneling technique combined with cystoscopy. We performed this operation on two female patients. The first patient had a right lower-ureteral stricture after a laparoscopy-assisted vaginal hysterectomy, and the second patient had a left distal-ureteral stricture after a left laparoscopic oophorectomy, which was performed for endometriosis. We performed laparoscopic intravesical ureteral reimplantations with a psoas hitch using submucosal tunneling after a submucosal injection of normal saline was provided under cystoscopy. The operative times were 325 and 280 minutes, respectively. The estimated blood loss was 300 mL in the first case and 120 mL in the second. The hospital stays were 5 and 3 days, respectively. There were no postoperative complications. Follow-up voiding cystourethrography and intravenous urography demonstrated normal compliance and function of the kidneys and ureters with no vesicoureteral reflux. Laparoscopic intravesical nonrefluxing ureteroneocystostomy with a psoas hitch is a safe and feasible procedure. Cystoscopic submucosal injection of normal saline during submucosal tunneling is beneficial.