Laparoscopic Pelvic Surgery Research Articles

The feasibility of laparoscopic extended pelvic surgery for rectal cancer.

The present study aimed to assess the safety and feasibility of laparoscopic extended pelvic surgery for primary or recurrent rectal cancer. The data on 77 patients, who underwent extended pelvic surgery between February 2008 and June 2014, were retrospectively analyzed. The patients were divided, based on their treatment history, into an open surgery (OS) group (n=41) and a laparoscopic surgery (LS) group (n=36). The operative time in the LS group was significantly longer than that in the OS group (766 vs. 561min; p<0.001). In contrast, the LS group was associated with a significantly lower volume of intraoperative blood loss (195 vs. 923ml; p<0.001), fluid balance (5.38 vs. 8.23ml/kg/h; p<0.001) and rate of complications (40.0 vs. 68.3%; p=0.035), and a significantly shorter postoperative hospital stay. The postoperative levels of colloid osmotic pressure and albumin were significantly higher in the LS group. The operative time of the LS group was longer than that of the OS group; however, the LS group experienced less blood loss and fewer complications. Moreover, LS was associated with a reduction in intraoperative infusions and a reduced fluid balance, which maintained homeostasis.

The impact of pneumoperitoneum and Trendelenburg positioning on respiratory system mechanics during laparoscopic pelvic surgery in children: a prospective observational study.

The aim of this study was to describe the changes in respiratory system compliance and other measures of respiratory mechanics associated with peritoneal insufflation (12mmHg pressure) with carbon dioxide (PNP12) and 20° Trendelenburg positioning (TDG20) in pediatric patients undergoing laparoscopic surgery for abdominal cryptorchidism. Twelve subjects with abdominal cryptorchidism undergoing orchiopexy were enrolled in the study. General anesthesia was conducted with sevoflurane/O2/air, fentanyl, and rocuronium. Pressure-controlled ventilation with a peak inspiratory pressure (PIP) of 10-15cm H2O and a positive end-expiratory pressure of 5cm H2O was titrated to achieve a tidal volume (VT/kg) of 6-10mL·kg(-1) and end-tidal carbon dioxide (EtCO2) of 35-40mmHg. Adjustments of PIP and respiratory rate (RR) were made to maintain the initial VT/kg and EtCO2<50mmHg. Measurements of weight-corrected dynamic compliance (Cdyn/kg), VT/kg, and EtCO2 were recorded at baseline, after PNP12, at TDG20, and again after deflation and return to the level position. Adjustments in PIP were required in all subjects to maintain the target VT/kg. The Cdyn/kg decreased 42% (95% confidence interval [CI]: 30 to 51; P<0.001) after PNP12, and it remained below baseline until deflation. The TDG20 caused only minimal additional reductions in Cdyn/kg (10% decrease; 95% CI: 0 to 19; P=0.048). The VT/kg decreased 42% (95% CI: 31 to 52; P=0.048) with PNP12, and after TDG20, it decreased a further 10% (95% CI: 4 to 19; P=0.038). After deflation, the VT/kg increased by 56% (95% CI: 28 to 90; P=0.001) and was then adjusted back to the initial values. The PNP12 significantly decreases Cdyn/kg and VT/kg in pediatric patients. The use of TDG20 produces a relatively minor additional impact in respiratory mechanics. This study emphasizes the need to adjust ventilator settings to maintain normal gas exchange during this procedure.

Pelvic Floor Support Defect in Apical Anterior Vaginal Prolapse with Cervical Hypertrophy. Review with Case Report in a 20-year-old Cadaver

Apical anterior vaginal wall prolapse (AVWP) with central defect is uncommon in young non hysterectomized patients causing considerable mortality after the fourth decade of life. Its high propensity to recurrence poses the greatest challenge to pelvic reconstructive surgeons. Approximately 40% of women with prolapse have hypertrophic cervical elongation and the extent of elongation increases with greater degrees of prolapse. Women with prolapse either have inherent hypertrophic elongation of the cervix which predisposes them to prolapse or the downward traction in prolapse leads to cervical elongation. The Pelvic Organ Prolapse Quantification (POP-Q) examination includes measurement of the location of the posterior fornix (point D) with the assumption that this measurement is associated with cervical elongation. Multifocal site involvement with apical and perineal descent primarily afflicts elderly, postmenopausal women after the fourth decade while cervical hypertrophic elongation with prolapse is observed in younger women less than 40 years of age. A review of the anatomical implication of the association of cervical hypertrophy in prolapse is carried out in this article. We observed a combination of distension type anterior vaginal prolapse with apical descent and cervical hypertrophy in a 20-year-old cadaver during routine dissection for undergraduate medical students at Sikkim Manipal Institute of Medical Sciences in 2013. Distension type anterior vaginal prolapse with central defect is rarer as most reported cases are of the displacement type, paravaginal defect. Hypertrophic cervical elongation is either the cause or consequence of prolapse and its identification before reconstructive surgery is paramount as uterine suspension in the face of cervical elongation is contraindicated. Inappropriate identification of all support defects and breaking of tissues is the primary cause of failure of laparoscopic pelvic reconstructive surgery.

Intraoperative laparoscopic complications for urological cancer procedures.

To structure the rate of intraoperative complications that requires an intraoperative or perioperative resolution. We perform a literature review of Medline database. The research was focused on intraoperative laparoscopic procedures inside the field of urological oncology. General rate of perioperative complications in laparoscopic urologic surgery is described to be around 12.4%. Most of the manuscripts published do not make differences between pure intraoperative, intraoperative with postoperative consequences and postoperative complications. We expose a narrative statement of complications, possible solutions and possible preventions for most frequent retroperitoneal and pelvic laparoscopic surgery. We expose the results with the following order: retroperitoneal laparoscopic surgery (radical nephrectomy, partial nephrectomy, nephroureterectomy and adrenalectomy) and pelvic laparoscopic surgery (radical prostatectomy and radical cystectomy). Intraoperative complications vary from different series. More scheduled reports should be done in order to better understand the real rates of complications.

Laparoscopic and Robot-Assisted Pelvic Surgery: Pathophysiologic Considerations for Better Patient Selection

Laparoscopic and Robot-Assisted Pelvic Surgery: Pathophysiologic Considerations for Better Patient Selection

Usefulness of Moistening Seprafilm Before Use in Laparoscopic Surgery

Seprafilm is an ideal synthetic adhesion barrier, but its insertion into the abdomen in laparoscopic surgery is difficult because of its stiff and brittle nature. We tested the usefulness of a novel technique of moistening Seprafilm before use to increase its flexibility before insertion through a trocar during laparoscopic surgery. Laparoscopic pelvic surgeries that were followed by insertion of Seprafilm were evaluated in 67 women. A piece of Seprafilm (1/6 or 1/4 the size of a full sheet) was placed on gauze moistened with saline solution to soften it. The prepared piece was then rolled, inserted with forceps through a 12-mm trocar port, and placed at the intended site. A total of 245 pieces of Seprafilm sheets were pretreated and inserted using a 12-mm trocar port with a success rate of 100% and placed correctly with a success rate of 80.0% (196 of the 245 pieces). The mean total time required for placement of all pieces per surgery was 601±248 seconds. This is a simple and effective technique that enables the film to be applied securely without breaking and without the need for special equipment.

Antibiotic Prophylaxis in Gynecologic Laparoscopy: Study Protocol for a Randomized Controlled Trial

Background: Laparoscopy is a surgical procedure indicated for most gynecological pathologies. It presents numerous advantages over laparotomy; among these are lower rates of surgical site infection and less febrile comorbidity. Despite this, the use of antibiotic prophylaxis is widely accepted and performed by most gynecologists. However, no evidence exists in the literature to support the routine use of antibiotics in the prophylaxis of wound infection in laparoscopic pelvic surgery. Objective: This study aims to assess the surgical site infection rates for gynecological laparoscopies, not involving the opening of hollow viscera, among patients receiving or not antibiotic prophylaxis. Methods: This is a clinical, prospective, double-blind, randomized study. A total of 216 women with gynecological pathologies, undergoing laparoscopic surgical approach, will be consecutively selected. The patients will be randomly allocated to either the placebo group (n=108), to receive 10 mL of intravenous sterile saline, or to the antibiotic group (n=108), to receive 1 g of intravenous cefazolin 30 minutes before the surgery. To evaluate the incidence of surgical site infection, criteria of the Centers for Disease Control and Prevention (CDC) will be used. The patients will be evaluated weekly for 30 days. Discussion: The CDC “Guideline for Prevention of Surgical Site Infection” provides recommendations for the prevention of surgical site infections. However, for some practices, no recommendations are offered, due to a lack of consensus or insufficient evidence on the effectiveness of preventative measures. Interventions to reduce the incidence of surgical site infections are essential to reduce not only morbidity, but also costs to patients and society. Trial registration: ClinicalTrials.gov identifier: NCT01991834.

Cost efficiency of target-controlled inhalational anesthesia.

Background:Cost and environmental pollution are two prime concerns with general anesthesia. We hypothesized that target-controlled (TC) anesthesia drug delivery system also called as end-tidal (ET) control is an effective and safe system that would reduce the cost and also environmental pollution.Materials and Methods:We studied 200 patients undergoing laparoscopic abdominal and pelvic surgeries and randomly distributed those in 2 groups of 100 each, TC and manual-controlled (MC) group. We reviewed the two groups in term of consumption of gases, time required to achieve the ET concentration of sevoflurane of 1.5%, maximum inspired concentration of sevoflurane achieved, and number of adjustments required to maintain the depth of anesthesia.Results:We found that the consumption of nitrous oxide and sevoflurane was significantly less in TC group than MC group (P < 0.05), oxygen consumption was also less in TC group but not statistically significant. The time required to achieve the desired levels, maximum inspired sevoflurane concentration achieved, and the number of drug delivery adjustments required were statistically significant in TC group (P < 0.05). As the consumption reduced in TC group, the cost of the inhalational anesthesia reduced by approximately Rs. 64/h ($1.12) and thus the environmental pollution.Conclusion:We concluded from our study that ET control is a good system for conserving the consumption of gases and thus is efficient as it reduces both the cost and the environmental pollution.

Antimullerian hormone changes after laparoscopic ovarian cystectomy for endometrioma compared with the nonovarian conditions.

Laparoscopic ovarian cystectomy is recommended for surgical procedure of endometrioma. The negative impact on ovarian reserve following removal had been documented. Little evidence had been reported for nonovarian originated effects. Objective. To evaluate the impact of laparoscopic ovarian cystectomy for endometrioma on ovarian reserve, measured by serum antimullerian hormone (AMH), compared to nonovarian pelvic surgery. Materials and Methods. A prospective study was conducted. Women who underwent laparoscopic ovarian cystectomy (LOC) and laparoscopic nonovarian pelvic surgery (NOS) were recruited and followed up through 6 months. Clinical baseline data and AMH were evaluated. Results. 39 and 38 participants were enrolled in LOC and NOS groups, respectively. Baseline characteristics (age, weight, BMI, and height) and preoperative AMH level between 2 groups were not statistically different. After surgery, AMH of both groups decreased since the first week, at 1 month and at 3 months. However, as compared to the LOC group at 6 months after operation, the mean AMH of the NOS group had regained its value with a highly significant difference. Conclusion. This study demonstrated the negative impact of nonovarian or indirect effects of laparoscopic surgery to ovarian reserve. The possible mechanisms are necessary for more investigations.

Laparoscopic Gynae-oncological Procedures: Lessons Learnt After a Single Institution Audit of Complications and Their Management in 567 Consecutive Patients

To retrospectively evaluate the complications of the laparoscopic pelvic surgeries and to formulate the guidelines to avoid them. Retrospective study (Canadian Classification). Advanced Laparoscopic Institute. Nine hundred and seven operated for gynecological malignancies. Laparoscopic surgeries. 567 women suffering from different pelvic conditions were studied in a period of 60months. The median age of the patient was 35 (11-80). Complications occurred in 32 patients (32/567, 5.5%). The overall incidence of urinary tract injury in all the advanced cases at our institute was 2.1% (12/567). The incidence of bowel injury at our center was 1.76%. The incidence of vascular injury at our institute was 1.76% (10/567). Laparoscopic complications are different than those seen following open surgeries. Anticipation, early recognition, and timely intervention help to reduce morbidity. Laparoscopic management of complications is possible. Formulating standard guidelines can help to avoid many such complications.

The effects of combined epidural and general anesthesia on the autonomic nervous system and bioavailability of nitric oxide in patients undergoing laparoscopic pelvic surgery

Pneumoperitoneum during laparoscopic surgery is known to affect visceral blood flow and result in oxidative stress. Whether epidural anesthesia will effectively reduce visceral ischemia and oxidative stress by blocking the sympathetic nervous system (SNS) during laparoscopic surgery has not been proven. Forty-five patients who were to undergo robot-assisted laparoscopic prostatectomy were randomly assigned to the combined general-epidural anesthesia group (group GE, n = 22) or to the general anesthesia group (group G, n = 23). Blood pressure, heart rate, and the balance between sympathetic and parasympathetic nervous system activity as measured by heart rate variability were recorded at 10 min after induction of anesthesia (T1), 60 (T2) and 120 (T3) min after intra-abdominal CO(2) insufflation, and 10 min after returning the patient to the supine position following CO(2) exsufflation (T4). Arterial blood gas analysis and blood sampling for measurements of nitrite (NO(2-)) and malondialdehyde (MDA) were performed at all time points. Intraoperative mean blood pressure was significantly lower in group GE compared with group G. The low-frequency to high-frequency ratio was significantly increased after induction of pneumoperitoneum in group G but was unchanged in group GE. Plasma levels of nitrite decreased after pneumoperitoneum induction in group G while there was no change in group GE. A significant increase in MDA levels was seen in group G after pneumoperitoneum induction and were higher than group GE at T3 and T4. The 24-h urine output was higher in group GE than in group G on POD 1. The 24-h CrCl was higher in group GE on POD 1 but was not different between groups on POD 2. Combined epidural and general anesthesia effectively blocks SNS stimulation during laparoscopic surgery and reduces NO inactivation and oxidative stress.

Surgical treatment of ectopic pregnancy associated with predisposing factors of tuboperitoneal infertility

Objective: We sought to study the advantages of laparoscopic conservative treatment and pelvic reproductive surgery in patients with ectopic pregnancy and predisposing factors of tuboperitoneal infertility. Material and methods: Patients who had undergone laparoscopic treatment for ectopic pregnancy were considered, with factors for tuboperitoneal infertility, while patients who underwent previous salpingectomy or assisted reproductive technology were excluded. The groups treated by salpingotomy (conservative) or salpingectomy (radical) were compared in terms of spontaneous intrauterine pregnancy rate, cumulative one-year pregnancy rate and recurrence of ectopic pregnancy. We considered patients treated with adhesiolysis, fimbrioplasty, and neosalpingostomy for tubal pathology as part of the fertility surgery group. Results: Among 41 considered patients, 21 (51%) underwent conservative laparoscopic management of ectopic pregnancy. Twenty patients (49%) had salpingectomy. Despite the treatment of tuboperitoneal infertility factors in both groups, the pregnancy rate was significantly higher in the conservative group than in the radical one (76% vs 25%, p < 0.05). The overall cumulative rate of ectopic pregnancy recurrence was 22% and no significant difference was found between conservative and radical treatment (p 0.645). Conclusions:Salpingotomy should be preferred in all patients with ectopic pregnancy associated with factors of tuboperitoneal infertility. Infertility surgery clearly cannot help patients treated with salpingectomy, who obtain lower spontaneous pregnancy rates than those of the conservative group.

Initial experience of a novel ergonomic surgical chair for laparoscopic pelvic surgery

We present the initial experience of a novel surgical chair for laparoscopic pelvic surgery, the ETHOS™ (Bridge City Surgical, Portland, OR). The ETHOS chair has an adjustable saddle height that ranges from 0.89 to 1.22 m high, an overall width of 0.89 m, and a depth of 0.97 m. The open straddle is 0.53 m and fits most OR tables. We performed 7 pelvic laparoscopy cases with the 1st generation ETHOS™ platform including 2 laparoscopic ureteral reimplantations, 5 laparoscopic pelvic lymphadenectomies for staging prostate cancer in which one case involved a laparoscopic radical retropubic prostatectomy, performed by 2 different surgeons. All 7 pelvic laparoscopic procedures were successful with the ETHOS™ chair. No conversion to open surgery was necessary. Survey done by surgeons after the procedures revealed minimal stress on back or upper extremities by the surgeons from these operations even when surgery was longer than 120 minutes. Conversely, the surgical assistants still had issues with their positions since they were on either sides of the patient stressing their positions during the procedure. The ETHOS chair system allows the surgeon to operate seated in comfortable position with ergonomic chest, arms, and back supports. These supports minimize surgeon fatigue and discomfort during pelvic laparoscopic procedures even when these procedures are longer than 120 minutes without consequence to the patient safety or detrimental effects to the surgical team.

Laparoscopic or Laparoscopic-Assisted Pelvic Surgery in Small Infants: Our Experience

The objective of this study was to review our experience of laparoscopic (LA) or laparoscopic-assisted pelvic surgery (LAPS) in small infants. The medical records of 35 patients who underwent an LA or LAPS between January 2007 and June 2010 were studied and 21 patients who were younger than 1 year or whose weight was less than 10 kg were included. Indications, procedures, results, and complications were analyzed. The indications of surgery and procedures done were impalpable undescended testes (7 cases--3 single-stage orchidopexy and 4 Fowler Stephen stage I ligation of testicular vessels), Hirschsprung's disease (HD; 5 cases--all laparoscopic-assisted transanal pull-through), anorectal malformation (ARM; 3 cases--all laparoscopic-assisted pull-through), disorders of sexual differentiation (3 cases--1 herniotomy and 2 gonadal biopsy), sacrococcygeal teratoma (1 case--laparoscopic mobilization of pelvic component and posterior sagittal excision), and ovarian mass (2 cases; laparoscopic oophorectomy). There were 14 males, 4 females, and 3 of indeterminate sex. All procedures could be successfully completed without conversion. There was no anesthesia-related complication or need for postoperative ventilatory support. There were no immediate procedure-related complications. One female child with ARM had rectal mucosal prolapse; 1 HD case had rectovaginal fistula that healed following fecal diversion. The major advantages of laparoscopy in different indications were magnified access into the depth of pelvis and early frozen section biopsies in HD, accurate placement of neoanus in the center of muscle complex in ARM, early ligation of vessels and avoidance of laparotomy in sacrococcygeal teratoma, ease of decision making and better mobilization of vessels in undescended testes, and diagnostic accuracy and therapeutic procedure in ambiguous genitalia. Laparoscopic pelvic surgery in small infants is a safe procedure with advantage of magnification, access, and cosmesis.

Update on Gynecologic Surgery

Christ Hospital of Cincinnati (OH, USA) sponsored the 13th annual Pelvic Anatomy and Gynecologic Surgery Symposium held on 9–11 December 2010 in Las Vegas (NV, USA). Course directors were Mickey M Karram and Michael S Baggish. Invited faculty included Tommaso Falcone and Mark Walters, both from the Cleveland Clinic Foundation in Cleveland (OH, USA). In addition, John Gebhart from the Mayo Clinic in Rochester (MN, USA) and Javier F Magrina from the Mayo Clinic Scottsdale (AZ, USA) rounded out the speakers' list. The symposium gathered renowned experts in open, vaginal, laparoscopic and robotic pelvic surgeries to discuss issues and controversies surrounding minimally invasive gynecologic surgery.

Use of Bolster in Laparoscopic Pelvic Surgery

The operative field in laparoscopic pelvic surgery is hindered by the presence of small bowel in the pelvis. Traditionally this problem in overcome by giving a steep head low. Disadvantages of this include an awkward patient postion, decreased pulmonary tidal volumes and curves, and the possibility of hemodynaic overload on the heart. This steep head low is a major problem in the obese patient wher all the abovesaid factors are aggraveted. We propose an indigenous bolster, that can be made with ease, and placed in the back at the level of the anterior superior iliac spines. This bolster splits the pelvis into two halves pushing the small bowel into the upper half, leaving a clear operative field in the pelvis. The need for steep head low is decreased. We have been using this bolster for all our laparoscopic pelvic surgeries since last 5 years.

30 Robotic technology enables feasible laparoscopic radical cystectomy with acceptable nodal yield even for the laparoscopic pelvic surgery naive surgeon: Analysis of the learning curve from Korean single center

30 Robotic technology enables feasible laparoscopic radical cystectomy with acceptable nodal yield even for the laparoscopic pelvic surgery naive surgeon: Analysis of the learning curve from Korean single center

No Supplemental Muscle Relaxants Are Required During Propofol and Remifentanil Total Intravenous Anesthesia for Laparoscopic Pelvic Surgery

No administration of supplemental muscle relaxants may be beneficial to the recovery of the ambulatory laparoscopic surgery. For this study, we compared the cardiorespiratory factors during propofol and remifentanil anesthesia for laparoscopic pelvic surgery (LPS) with or without supplemental muscle relaxants. In total, 56 healthy female patients scheduled to undergo laparoscopic pelvic surgeries were randomly assigned to two groups (A and B). Anesthesia was induced with lidocaine 30 mg, propofol target organ concentration 5.0 microg/mL, remifentanil 3.0 ng/mL, and rocuronium 0.6 mg/kg intravenously (i.v.). After tracheal intubation, anesthesia was maintained with 2.0-5.0 microg/mL of propofol and 1-4 ng/mL of remifentanil i.v. All the patients' lungs were mechanically ventilated in both groups and intermittent bolus doses of rocuronium (0.15 mg/kg i.v.) were administered in group A-however, not in group B. Heart rate (HR) and systolic arterial pressure (SAP), diastolic arterial pressure (DAP), end-tidal carbon-dioxide concentration (EtCO(2)), peak inspiratory pressure (PIP), expired minute ventilation (MV), intra-abdominal pressure (IAP), and temperature were measured during the pneumoperitoneum. There were no group differences in HR, SAP, DAP, EtCO(2), PIP, IAP, MV, PaO(2), PaCO(2), and temperature between groups A and B. No supplemental muscle relaxants are required during propofol and remifentanil total i.v. anesthesia for LPS.

No supplemental neuromuscular blockers are required during propofol and remifentanil total intravenous anesthesia for laparoscopic pelvic surgery

No supplemental neuromuscular blockers are required during propofol and remifentanil total intravenous anesthesia for laparoscopic pelvic surgery

Evaluation of laparoscopic radical cystectomy for loco-regionally advanced bladder cancer

We studied the safety and feasibility of laparoscopic radical cystectomy (LRC) in patients with loco-regionally advanced bladder cancer and report the short-term oncological outcome. This study comprised a total of 13 patients (10 males, 3 females), who presented with myriad of symptoms and on imaging they were found to have radiologically evident advanced disease (6 pelvic lymphadenopathies, 10 extravesical tumor extensions, three prostate/seminal vesical invasions). In view of recalcitrant symptoms (hematuria, frequency and irritative voiding) all patients underwent LRC and bilateral modified pelvic lymphadenectomy with ileal conduit urinary diversion. Mean age of the patients was 56.3 years. Mean operative time was 310 min with an average blood loss of 556 ml. No major intra-operative complications were noted. One patient died in the post-operative period due to sepsis. Histopathology report revealed pT3b N0 in two patients; pT3b N1 in four; pT3b N2 in three; pT4a N0 in one, and pT4aN1 in three patients. Adjuvant chemotherapy was administered in nine patients. At mean follow up of 18 months (range 6-28), seven patients are alive and cancer-free, while two patients are alive with metastases. LRC provides an alternative approach for treatment of patients with loco-regionally advanced bladder cancer, who suffer from recurrent hematuria and severe irritative voiding symptoms, in whom open surgery was the standard approach hitherto. However, it should be considered experimental and should be attempted only by surgeons who have significant experience of laparoscopic pelvic surgery and advanced skills, and after discussing the potential risks and benefits with the patient.