Time Of Laparoscopic Surgery Research Articles

Expression of leukemia inhibitory factor in the endometrium in abnormal uterine cavities during the implantation window

To investigate the expression of the implantation factors leukemia inhibitory factor (LIF), interleukin-11 (IL-11), and IL-6ST/gp130 in the endometrium to examine the relationship between loss of implantation and abnormal uterine cavity. Case-control study. Department of Obstetrics and Gynecology, Tokyo Medical University. Subjects comprised 41 patients in the abnormal uterine cavity group who underwent resection of a uterine submucosal myoma or an endometrial polyp by transcervical resectoscopy (TCR) and 18 patients in the control group who underwent laparoscopic surgery. In the abnormal uterine cavity group, endometrial tissue specimens were obtained before resection under hysteroscopy. In the control group, endometrial tissue specimens were obtained by curettage at the time of laparoscopic surgery. We divided the patients into four groups according to menstrual cycle and measured the endometrial expression of LIF, IL-11, and IL-6ST/gp130 with the use of quantitative real-time reverse-transcription polymerase chain reaction. Significant increases in LIF and IL-11 mRNA expression were recognized during the midsecretory phase of the menstrual cycle in the control group. However, no difference in IL-6ST/gp130 mRNA expression was observed in any phase during the menstrual cycle in either group. In terms of LIF and IL-11 mRNA expression at the midsecretory phase, the abnormal uterine cavity group showed a significantly decreased LIF mRNA expression compared with the control group. LIF mRNA expression was significantly decreased in abnormal uterine cavities during the midsecretory phase, indicating that endometrial cavity defects are a possible cause of poor reproductive outcomes.

Timing of laparoscopic surgery in the neoadjuvant treatment of rectal cancer

Timing of laparoscopic surgery in the neoadjuvant treatment of rectal cancer

Laparoscopic lymph node dissection around the inferior mesenteric artery with preservation of the left colic artery

Curative resection of sigmoid and rectal cancer includes "high tie" of the inferior mesenteric artery (IMA). However, IMA ligation compromises blood flow to the anastomosis, which may increase the leakage rate. Accordingly, some surgeons employ a technique of lymph node (LN) dissection around the IMA, preserving the IMA and left colic artery (LCA). The same technique was reported to need longer time in laparoscopic surgery due to technical difficulties. We present herein a simple and secure method of laparoscopic LN dissection around the IMA that allows preservation of the IMA and LCA, and report the operative results. Our method involves peeling off the vascular sheath from the IMA and dissection of the LN around the IMA together with the sheath. The feasibility of the technique was evaluated in 72 consecutive cases of laparoscopic resection of sigmoid and rectal cancer. The IMA was ligated at its root in 27 cases (high tie, group A). Lymph nodes around the IMA were dissected with preservation of the IMA and LCA in 21 cases (group B). The root of the superior rectal artery was ligated in 24 cases of Tis and T1N0 ("low tie," group C). Mean operative time was 207.6, 221.2, and 198.5 min for group A, B, and C, respectively. Respective blood loss was 47.8, 44.0, and 58.5 g, and mean numbers of harvested LN were 17.3, 16.3, and 10.7. None of the operative results of groups A and B were different statistically. LN dissection was not associated with any morbidity. Our method allows equivalent laparoscopic lymph node dissection to the high tie technique without excessive operative time or bleeding.

448 Laparoscopic Paraesophageal Hernia Repair with Mesh and Collis Gastroplasty with Nissen Fundoplication

In this video presentation we are presenting a patient with a submucosal mass at the gastroesophageal junction (GEJ). At time of laparoscopic surgery, the mass was adherent to the GEJ and extended into the distal left esophagus. Resection of the mass included a portion of the lower esophageal sphincter and distal left esophagus. This area was then reconstructed primarily over a 42 Fr tapered Bougie with running 3.0 and 2.0 Vicryl® suture in two layer fashion. The patient did well post-operatively and was discharged home on day six.

449 Medical and Surgical Treatment of Chronic Anal Fissure: Prospective Longer-Term Results

In this video presentation we are presenting a patient with a submucosal mass at the gastroesophageal junction (GEJ). At time of laparoscopic surgery, the mass was adherent to the GEJ and extended into the distal left esophagus. Resection of the mass included a portion of the lower esophageal sphincter and distal left esophagus. This area was then reconstructed primarily over a 42 Fr tapered Bougie with running 3.0 and 2.0 Vicryl® suture in two layer fashion. The patient did well post-operatively and was discharged home on day six.

GS13 SPOT MARKING FOR LAPAROSCOPIC COLECTOMIES

Purpose: Mechanical Bowel Preparation (MBP) is often used by surgeons for patients undergoing Laparoscopic Colectomy (LC) due to the concern that small lesions normally palpable at open surgery may not be seen at the time of laparoscopic surgery. This study sought to determine whether preoperative marking of the colonic primary at the time of colonoscopy with Spot® could overcome this concern.Methodology: All patients suitable for a LC had Spot® marking performed at their colonoscopy. One millilitre of Spot® marking was injected submucosally in 3 positions around the circumference of the lumen at least 5 cm distal to the lesion. The first 100 LC performed by the surgeon for lesions were audited for the purpose of this study, and MBP was not used while all patients received preoperative immunonutrition.Results: Overall mortality was 0%. The anastomotic leak rate was 2% (1 reoperation, 1 low output fistula). Conversion rate was 23%. Spot® marking was successfully identified at laparoscopy in all 100 cases. No cases were converted as a result of failure to identify the marking, however 1 case required an extension in the final incision due to the fact the Spot® marking had been placed proximal to the lesion. Anastomoses were performed “across” the Spot® marking on 3 occasions with no untoward effect.Conclusion: Spot® marking is a safe and effective way to mark lesions in the colon in order to facilitate LC without the need for MBP.

Small bowel necrosis and enterocutaneous fistulae resulting from iatrogenic spillage of dermoid cyst contents at the time of laparoscopic surgery

A 38-year-old lady with a 14 × 8 × 13-cm dermoid cyst underwent a laparoscopic left salpingo-oophrectomy. Intra-operatively, there was accidental spillage of the cyst contents into the peritoneal cavity. The spilled contents were completely sucked out and a thorough peritoneal lavage was done to decrease the risk of chemical peritonitis. The patient developed disseminated granulomatous chemical peritonitis, small bowel necrosis, multiple enterocutaneous fistulae, intra-abdominal, and anterior abdominal wall abscesses. Following four further surgeries, she finally made a recovery 6 months later. Chemical peritonitis and intra-abdominal abscesses are rare complications. Bowel necrosis and enterocutaneous fistulae have not been described. This case report will increase awareness of these rare complications and in their prevention and management. A literature review of strategies to prevent spillage of dermoid cyst contents at surgery is also presented.

Vulvar Endometriosis

The etiology of endometriosis-associated deep dyspareunia may include direct endometriosis-specific factors (eg, stage or invasiveness of disease) and/or indirect contributors such as bladder/pelvic floor dysfunction (eg, related to myofascial mechanisms or nervous system sensitization).This study aimed to determine whether bladder/pelvic floor tenderness and painful bladder syndrome were associated with severity of deep dyspareunia in women with endometriosis, regardless of Stage (I/II vs III/IV) or other endometriosis-specific factors.Observational study from a prospective patient registry (January 2014 to December 2016) at a tertiary centre for endometriosis. Included were women aged 18 to 49 years who had surgical removal and histopathologic confirmation of endometriosis at the centre. Cases with Stage I/II vs Stage III/IV endometriosis were analyzed separately. Bivariate associations with the primary outcome (severity of deep dyspareunia) were tested for bladder/pelvic floor tenderness, painful bladder syndrome, as well as endometriosis-specific factors identified at the time of laparoscopic surgery (eg, deep infiltrating endometriosis) and demographic factors (eg, age). Multivariable ordinal logistic regression was carried out to adjust for factors associated with the primary outcome.Primary outcome was severity of deep dyspareunia on an 11-point numeric rating scale, categorized as none/mild (0–3), moderate (4–6), and severe (7–10), from a preoperative self-reported questionnaire.Overall, 411 women had surgically confirmed endometriosis: 263 had Stage I/II and 148 had Stage III/IV endometriosis. Among women with Stage I/II endometriosis, severity of deep dyspareunia was associated with both bladder/pelvic floor tenderness and painful bladder syndrome (AOR = 1.94, 95% CI: 1.11–3.38, P = .019 and AOR = 1.99, 95% CI: 1.15–3.44, P = .013, respectively), independent of endometriosis-specific factors or other factors associated with deep dyspareunia severity. Similar associations were found in women with Stage III/IV endometriosis (bladder/pelvic floor tenderness AOR =2.51, 95% CI: 1.25–5.02, P = .01, painful bladder syndrome: AOR = 1.90, 95% CI: 1.01–3.57, P = .048).Myofascial or nervous system mechanisms may be important for deep dyspareunia in women with endometriosis, even in those with moderate-to-severe disease (Stage III/IV).Strengths include the prospective registry, and histological confirmation of endometriosis and staging by experienced endometriosis surgeons. Limitations include assessment of only one pelvic floor muscle (levator ani).In women with Stage I/II or Stage III/IV endometriosis, severity of deep dyspareunia was strongly associated with bladder/pelvic floor tenderness and painful bladder syndrome, independent of endometriosis-specific factors, which suggests the role of myofascial or sensitization pain mechanisms in some women with deep dyspareunia.Orr NL, Noga H, Williams C, et al. Deep Dyspareunia in Endometriosis: Role of the Bladder and Pelvic Floor. J Sex Med 2018;15:1158–1166.

Laparoscopic Surgery for Large Benign Ovarian Cysts

In previous studies of laparoscopic surgery for women with ovarian cysts, most patients had small cysts. The present prospective study evaluated the laparoscopic approach in 33 consecutive women operated on during a 7-year period for ovarian cysts having a maximum diameter of 10 cm or more. All had laboratory and radiological features suggesting benign disease. Participants ranged in age from 17 to 73 years, averaging 45 years. The mean body mass index was 30, with a range of 21 to 42. Prospective patients whose maximum cyst diameter exceeded 30 cm were excluded from the study. Laparoscopic surgery proved effective in all but 2 instances, for a success rate of 94%. Two patients with adhesions were converted to laparotomy. No surgical or postoperative complications were recorded. Operating time averaged 82 minutes, and estimated blood loss, 89 mL. The hospital stay averaged just under 1 day; more than two-thirds of patients were discharged on the day of surgery. The procedures most frequently performed were unilateral salpingo-oophorectomy (SO) and laparoscopically assisted vaginal hysterectomy with bilateral SO. Cysts were extracted by aspiration through the vagina in 11 cases, by a lower quadrant incision in 5, and via an umbilical incision in 15. The most common pathologic finding was serous cystadenoma, followed by mucinous cystadenoma, dermoid, endometriosis, benign epithelial-lined cyst, and-in 2 cases-borderline ovarian tumor. All 4 women who were pregnant at the time of laparoscopic surgery, from 14 to 18 estimated weeks of gestational age, had a good outcome. These findings support accumulating evidence that laparoscopic surgery is an effective and safe procedure for removing large benign ovarian cysts.

Port-site and liver metastases after laparoscopic pelvic and para-aortic lymph node dissection for surgical staging of locally advanced cervical cancer

Recently, we experienced a case of port-site and liver metastases after 75 cases of laparoscopic transperitoneal pelvic lymph node dissection (PLND) and para-aortic lymph node dissection (PALND) for surgical staging of locally advanced cervical cancer. A 45-year-old-woman with stage IIB cervical adenocarcinoma underwent laparoscopic PLND and PALND for surgical staging. There was no intraperitoneal disease and cervical tumor was not manipulated at the time of laparoscopic surgery. Pathologic examination revealed only one micrometastasis in left internal iliac lymph node (LN), measuring 1 mm, of the 60 pelvic and para-aortic LNs removed. She received concurrent chemoradiation therapy and pelvic mass disappeared completely. One month after the completion of therapy, both lateral and umbilical port-site and liver metastases were detected. We conclude that although cases of port-site metastasis have mostly occurred after extensive disease, the possibility of such complication should be kept in mind at laparoscopy of early cancer and laparoscopy which does not manipulate primary tumor.

Comparison of Nd:YAG Surgical Laser and Remorgida Bipolar Electrosurgery Forceps for Canine Laparoscopic Ovariectomy

To investigate and compare technique, surgical time, and complications of canine laparoscopic ovariectomy using Nd:YAG surgical laser and Remorgida bipolar electrosurgery forceps. Randomized, prospective clinical trial. Female dogs (n=40) for elective ovariectomy. Dogs had bilateral ovariectomy with one ovary randomly assigned to removal by use of Nd:YAG surgical laser with a 600 mum optical fiber in contact mode and the other ovary to removal by use of a Remorgida forceps (featuring bipolar electrocoagulation with simultaneous sharp resection). Duration of predetermined surgery intervals and complications were compared between techniques. Additionally, the effects of several intraoperative variables on surgical time were evaluated. Ovariectomy by use of Remorgida forceps required significantly less time than laser ovariectomy but intraoperative hemorrhage was not reduced. Surgical time was significantly increased in obese dogs, depending on the amount of fat in the ovarian ligament. Intraoperative hemorrhage had no significant influence on surgical time. Both ovariectomy techniques were effective but the Remorgida forceps can be used as a relatively inexpensive, stand-alone device that decreases surgical time compared with Nd:YAG laser ovariectomy. Novel techniques, such as laser and combined bipolar electrosurgical and cutting forceps aim to reduce surgery duration, complication rates and recovery time in laparoscopic surgery.

Port-site and liver metastases after laparoscopic pelvic and para-aortic lymph node dissection for surgical staging of locally advanced cervical cancer

Recently, we experienced a case of port-site and liver metastases after 75 cases of laparoscopic transperitoneal pelvic lymph node dissection (PLND) and para-aortic lymph node dissection (PALND) for surgical staging of locally advanced cervical cancer. A 45-year-old-woman with stage IIB cervical adenocarcinoma underwent laparoscopic PLND and PALND for surgical staging. There was no intraperitoneal disease and cervical tumor was not manipulated at the time of laparoscopic surgery. Pathologic examination revealed only one micrometastasis in left internal iliac lymph node (LN), measuring 1 mm, of the 60 pelvic and para-aortic LNs removed. She received concurrent chemoradiation therapy and pelvic mass disappeared completely. One month after the completion of therapy, both lateral and umbilical port-site and liver metastases were detected. We conclude that although cases of port-site metastasis have mostly occurred after extensive disease, the possibility of such complication should be kept in mind at laparoscopy of early cancer and laparoscopy which does not manipulate primary tumor.

Timing of urgent laparoscopic cholecystectomy does not influence conversion rate

Background: The optimal treatment of acute gallstone disease is urgent laparoscopic cholecystectomy, but there is confusion about the effect of delay in operation on conversion rates. Most reports suggest that delay beyond 3 or 4 days leads to a higher conversion rate. This study assessed the conversion rate in relation to the timing of laparoscopic surgery. Methods: This institution operates a specialist-led protocol for the urgent management of all admissions with acute gallstone disease. Data were collected prospectively over 6 months. Results: Between March and August 2002, 84 patients with acute gallstone disease underwent urgent laparoscopic cholecystectomy at the index admission with an overall conversion rate of 12 per cent. Four of 40 procedures carried out within 3 days of admission were converted, compared with six of 44 after 3 days. Five of 46 carried out within 4 days of admission were converted, compared with five of 38 after 4 days. There were no deaths and one common bile duct injury. Conclusion: As long as the procedure is carried out by experienced upper gastrointestinal surgeons working within a specialist-led protocol, the conversion rate for laparoscopic cholecystectomy can be as low as 12 per cent. The timing of urgent laparoscopic cholecystectomy has no impact on the conversion rate.

Vero cell co-culture counteracts the detrimental effects of hydrosalpinx fluid on the development of mouse embryos in vitro.

Recent studies have suggested that the hydrosalpinx has a negative effect on pregnancy outcome, with markedly diminished implantation and increased early pregnancy loss. Fluid from the hydrosalpinx may leak into and accumulate in the uterine cavity. It is not clear, however if this creates a hostile local environment in the uterus for embryo implantation or exerts a direct embryotoxic effect. This study was conducted to investigate the detrimental effects of hydrosalpinx fluid (HSF) on the development of mouse embryos in vitro and to demonstrate whether Vero cells overcome these adverse effects. HSF was collected from three women with bilateral hydrosalpinx at the time of laparoscopic surgery. Collected fluid was centrifuged and the supernatant was frozen at -20 degrees C. For co-culture, Vero cells were commercially obtained in a frozen state and cultured using Ham's F10 medium. Single-cell mouse embryos (B6CBAF1) were cultured for 5 days in 0, 0.4, 0.8, and 1.2% of HSF in media with and without Vero cells and examined daily to record the number of embryos reaching expanded blastocyst and hatching stage. Co-culture of mouse embryos with Vero cells at 0.8% HSF concentration significantly enhanced embryo development, but not at 1.2% hydrosalpinx fluid concentration. These results suggest that HSF is highly embryotoxic and Vero cells are likely to overcome these detrimental effects to some degree.

Case report of ovarian transposition and review of literature

ObjectivePelvic radiotherapy is frequently used to treat pelvic tumours in premenopausal women. As there is a high probability of premature ovarian failure in this situation, ovarian repositioning is often required. This can now be done laparoscopically. We aimed to develop a modified technique that maintained the relationship between the ovaries and the fallopian tubes for potential future conception without the requirement for further surgery.SettingA teaching hospital.SubjectAn 18‐year‐old girl with a medulloblastoma who after craniectomy required craniospinal irradiation. To avoid ovarian irradiation she was referred to our unit for ovarian transposition.InterventionAt the time of laparoscopic surgery the utero‐ovarian ligaments were divided and the ovaries were sutured as a unit to the psoas muscle without distortion of the fallopian tube.ResultAfter surgery, X‐ray examination revealed that the lateral displacement of the right ovary was insufficient and consequently the procedure was repeated on this side. The patient's gonadotrophin levels remained in the premenopausal range after surgery.ConclusionOvarian transposition that maintains the relationship between the ovaries and fallopian tubes can be achieved by laparoscopic surgery.

Port‐site recurrences following laparoscopic operations for gynaecological malignancies

To determine the frequency of port-site recurrences following laparoscopic surgical treatment of gynaecological malignancies metastatic at the time of surgery. Retrospective review of metastatic primary and recurrent gynaecological malignancies. Twenty-five women were studied. Twenty-four had metastatic disease at the time of laparoscopic surgery, 22 in association with a primary malignancy (cervix: n = 12, ovary: n = 7, endometrium: n = 3), and two in association with recurrent ovarian cancer; all received pelvic or extended field radiation or chemotherapy after surgery. One woman with Stage IIIC ovarian cancer, disease-free at the completion of neoadjuvant chemotherapy following laparotomy by a general surgeon, was included; she developed scalene node metastases 18 months after definitive laparoscopic surgery. Seventy-one 5 mm trocars and fifty 10 mm trocars (total n = 121) were used for surgery; thirty-one 10 mm trocar sites and forty-four 5 mm sites (total n = 75) received post-operative treatment with chemotherapy (n = 49) or radiation (n = 26). Four women (16%) developed recurrences in association with endometrial (n = 2) and cervical (n = 2) cancer at six trocar sites. All recurrences were associated with abdominopelvic and/or distant metastases, and all occurred at untreated 5 mm trocar sites. The difference in recurrence rates between 5 mm and 10 mm trocar sites (chi(2) = 6; P < 0.025), and between treated and untreated trocars (chi(2) = 5; P < 0.05) were both statistically significant (McNemar's test), but the effects of treatment and trocar size on the port-site recurrence rate were confounded. Port-site recurrences are local manifestations of disseminated disease that result from the enhancement of tumour growth characteristic of healing tissues and can be prevented by appropriate post-operative therapy.

腹腔鏡下大腸手術 本邦での大腸癌に対するＬａｐａｒｏｓｃｏｐｉｃ Ｓｕｒｇｅｒｙの現況 アンケート調査結果

A current status of laparoscopic bowel surgery for cancer in Japan was investigated with collaboration of the majority of main hospital in the country and by sponsership of Japanese society for cancer of colon and rectum.81 of 113 (71.7%) main surgical departments in Japan have introduced this procedures in practice since 1993.A total of 958 cases in the last 3 years (1994-1996) have been treated by this procedure and this number indicates 7% of all surgically treated cases of the colorectal cancer during the same peirod.796 of 958 cases (83%) were the early cancers without lymphnodes involvement. The laparoscopic bowel surgery has been generally indicated for the cancer in early stage.The cases converted from this procedure to usual open surgery were 54 (conversion rate is 6%). The main reason for conversion was technical difficulty due to intraabdominal dense adhesions.There were the early postoperative complications including, in 70 cases, local subcutaneus abscess in the place where the trockers were inserted at the time of laparoscopic surgery, anastomotic leakage in 18 cases, local bleedings in 13 cases, bowel obstructions with adhesions in 14 cases and port-site-hernia in 6 cases.

Timing of laparoscopic surgery in gallstone pancreatitis.

To study the effect of the timing of laparoscopic cholecystectomy following acute gallstone pancreatitis. University-based county teaching hospital. Retrospective case series. One hundred forty-two patients with gallstone pancreatitis treated by laparoscopic cholecystectomy between April 1991 and September 1993. There were 16 men and 126 women, with a mean age of 39.5 years. The mean serum amylase level at admission was 1616 U/L. All patients were operated on more than 48 hours after admission, after clinical and biochemical resolution of pancreatitis. Preoperative endoscopic retrograde cholangiopancreatography was performed in 25 patients (more than 48 hours after admission), with common bile duct stones being identified and removed in 10. Twenty patients had three or more Ranson's criteria. Of these, nine had laparoscopic cholecystectomy attempted within the first week of admission. Six (67%) of these patients required conversion to open procedures (two for common bile duct exploration, one for repair of a common hepatic duct injury, and three for anatomic distortion due to inflammation). The mean postoperative stay of the nine patients was 5.4 days. The other 11 patients with three or more Ranson's criteria were operated on after 1 week, and only two required conversion to open cholecystectomy (18%). The mean postoperative stay in these 11 patients was 2.3 days. The difference in conversion rate approached but did not reach statistical significance (P = .08). The postoperative stay, however, was significantly shorter in the group of patients who underwent late operations (P = .03). There were 122 patients with fewer than three Ranson's criteria. In this group, there was no difference in length of postoperative stay between patients operated on earlier and those operated on later (2.4 vs 3.9 days; P = .49; n = 74 and n = 48, respectively). Of these 122 procedures, eight were converted to open procedures (6.6%). There was no significant difference in conversion rates in these patients regardless of whether they were operated on earlier or later. Based on these data, we believe, first, that laparoscopic cholecystectomy is safe in patients recovering from gallstone pancreatitis (mortality rate, 0%; bile duct injury, 0.7%). Furthermore, early operation can safely be recommended in patients with mild pancreatitis. However, in patients with three or more Ranson's criteria, operation during the first week following admission is associated with an increase in operative complications, an increased rate of conversion, and longer postoperative stays.

Gallbladder Cancer Discovered During Laparoscopic Surgery: Potential for latrogenic Tumor Dissemination

We read with interest the article by Fong et al¹entitled "Gallbladder Cancer Discovered During Laparoscopic Surgery: Potential for latrogenic Tumor Dissemination." We would agree with the authors' concerns regarding the dissemination of cancer at the time of laparoscopic surgery if the tumor is violated. There have been several disturbing reports of port site recurrence following the resection of malignant neoplasms²and at sites distant from unsuspected tumors.³ In reviewing the authors' operative findings at the time of reexploration, only two of the patients had gallbladder carcinomas resectable for cure (those patients lacking hepatic or peritoneal metastases). Physicians in our practice and others who advocate aggressive treatment for gallbladder cancer, including Shirai and colleagues,⁴would not consider the seven patients with liver metastases as candidates for resection. Patients with a violation of their tumor can be cured, as we have shown in two of our own