Robotic Single-Site Hysterectomy versus Robot-Assisted Multiport Hysterectomy in Benign Gynecologic Diseases: A Retrospective Comparison of Clinical and Surgical Outcomes

OBJECTIVE: The purpose of this study was to compare clinical and surgical outcomes of robotic single-site hysterectomy (RSSH) and robot-assisted multiport hysterectomy (RH) in benign disease. METHODS: We retrospectively reviewed the medical records of 38 women who underwent RSSH (N=12) or RH (N=26) for the treatment of benign uterine disease between June 2015 and November 2017. RESULTS: There were no intergroup differences in parity, comorbidities, and number of previous abdominal surgery. Mean age was older (49.5±5.05 years vs. 44.4±3.54 years, P=0.001) and mean body mass index was higher (27.4±2.47 kg/m2 vs. 25.3±3.12 kg/m2, P=0.045) in RSSH group than RH group. Surgical outcomes, including operative time (165.0 minutes vs. 159.2 minutes, P=0.727), estimated blood loss (115.8±33.15 mL vs. 108.1±56.42 mL, P=0.662), uterus weight (445.9±157.21 g vs. 374.5±197.91 g, P=0.291), postoperative hospital stay (5.4±0.51 days vs. 5.8±1.20 days, P=0.289), postoperative hemoglobin change in day 1 (1.8±0.89 g/dL vs. 1.4±1.53 g/dL, P=0.431) and day 3 (2.1±1.32 g/dL vs. 1.7±1.83 g/dL, P=0.601), and perioperative complications did not significantly differ between two groups. The use of additional analgesics after 6 hours, 24 hours, and 48 hours, and mean NRS score after 6 hours, 24 hours, and 48 hours were not significantly different between two groups. CONCLUSION: RSSH might be an effective and safe alternative to RH, even if in older and/or obese women with large uteri.

Comparison of HE4, CA125, and Risk of Ovarian Malignancy Algorithm in the Prediction of Ovarian Cancer in Korean Women

This study is a multi-center clinical study, which aimed to compare CA125, HE4, and risk of ovarian malignancy algorithm (ROMA) in predicting epithelial ovarian cancer of Korean women with a pelvic mass. Prospectively, serum from 90 Korean women with ovarian mass was obtained prior to surgery. For control group, serum from 79 normal populations without ovarian mass was also obtained. The HE4 and CA125 data were registered and evaluated separately and ROMA was calculated for each sample. Total 67 benign tumors and 23 ovarian cancers were evaluated. Median serum levels of HE4 and CA125, and ROMA score were significantly higher in patients with ovarian cancer than those with benign ovarian tumor and normal population (P < 0.001). In ROC curve analysis for women with a pelvic mass, area under the curve (AUC) for HE4 and ROMA was higher than CA125. Statistical differences in each study compared to CA125 were marginal (P compared to CA125; 0.082 for HE4 and 0.069 for ROMA). Sub-analysis revealed that AUC for HE4 and ROMA was higher than AUC for CA125 in post-menopausal women with a pelvic mass, but there were no statistically significant differences (P compared to CA125; 0.160 for HE4 and 0.127 for ROMA). Our data suggested that both HE4 and ROMA score showed better performance than CA125 for the detection of ovarian cancer in women with a pelvic mass. HE4 and ROMA can be a useful independent diagnostic marker for epithelial ovarian cancer in Korean women.

A clinical analysis of 10 cases of relaparotomy after emergency postpartum hysterectomy / 대한산부인과학회지

OBJECTIVE: To analysis the 10 cases of relaparotomy for intractable hemorrhage after emergency postpartum hysterectomy with massive transfusion. METHODS: Between January 1995 and December 2008, relaparotomies for intractable hemorrhage and unstable vital sign after emergency postpartum hysterectomy with massive transfusion were performed on 10 patients. Medical records were reviewed and detailed to collect clinical data including patients' clinical status, causes of bleeding, duration from hysterectomy to relaparotomy, bleeding sites, procedures for bleeding control, amount of transfusions, complications and prognosis. RESULTS: In relaparotomies, the points of bleeding were identified in all cases and multiple bleeding foci than one bleeding focus were found, and procedures for bleeding control were performed. In 8 cases, the bleeding were controlled successfully and these patients recovered without long term sequales. But in the other 2 cases, although the bleeding controls were successful during relaparotomy and bleeding amount decreased after relaparotomy, but bleeding amount increased the next day and angiographic embolizations were performed. These patients died due to multi-organ failure and continued bleeding. In one of these cases, the endotracheal intubation had been done on arrival at our hospital with postpartum hemorrhage after vaginal delivery at private clinic. In another case, the cardiopulmonary resuscitation was performed on arriving at our hospital with intractable bleeding after postpartum subtotal hysterectomy in other hospital. CONCLUSION: In most cases, bleeding controls for intractable bleeding after postpartum hysterectomy were successful during and after relaparotomy in spite of development of dilutional coagulopthy due to massive transfusion, and resulted in rapid recovery and good prognosis. Even though dilutional coagulopthy was developed because of massive transfusion, relaparotomy was safe and effective procedure for management of intractable hemorrhage after emergency postpartum hysterectomy with clotting factor replacement. If personnel and adequate clotting factor replacement are available, relaparotomy should not be delayed for management of intractable hemorrhage and unstable vital sign after emergency postpartum hysterectomy.

Successful Embolectomy of a Pulmonary Saddle Embolism Post-cesarean Section Complicated by Cardiac Arrest: A Case Report / 대한구급학회지

A 41-year-old female underwent an uneventful cesarean section, which was followed by a pulmonary saddle embolism complicated by cardiac arrest. This case shows that successful embolectomy is possible, despite a potentially lethal pulmonary saddle embolism, 34 cm in length, and intra-operative cardiopulmonary resuscitation. We report our case and discuss the anesthetic considerations based on the literature.

Laparoscopic systemic retroperitoneal lymphadenectomy for women with low-risk early endometrial cancer

<p><b>INTRODUCTION</b>There is no consensus on the extent of lymphadenectomy and the appropriate patients for lymphadenectomy in low-risk patients with endometrial cancer. This study aimed to evaluate the feasibility and effectiveness of laparoscopic lymphadenectomy for low-risk patients with endometrial cancer.</p><p><b>MATERIALS AND METHODS</b>From January 2004 to May 2008, we reviewed the medical records of 28 patients with low-risk, endometrial cancer; endometrioid type, grade 1 or 2, and with a depth of myometrial invasion of less than one-half of the myometrium. All patients underwent laparoscopically-assisted staging surgery.</p><p><b>RESULTS</b>The median age and body mass index were 56 years (range, 28 to 75) and 25.5 kg/m(2) (range, 21.3 to 37.2). The median operating time, estimated blood loss, and length of hospital stay were 142 minutes (range, 110 to 410), 215 mL (range, 100 to 700), and 7 days (range, 3 to 19), respectively. No conversion to laparotomy was noted. The median number of harvested lymph nodes was 21 (range, 10 to 48) pelvic nodes and 12 (range, 4 to 21) para-aortic nodes. One (3.6%) patient presented pelvic lymph node metastasis and 2 (7.1%) presented isolated para-aortic lymph node metastasis. The complication rate was 14.3%. No recurrence in the vaginal vault, distant metastasis, port site metastasis was noted up to the last follow-up.</p><p><b>CONCLUSION</b>Systemic pelvic and para-aortic lymphadenectomy should be considered in all low-risk patients with endometrial cancer until it is concluded to be clinically insignificant through large-scale prospective research in the future. However, it will be difficult to explain statistical differences in survival rates according to lymphadenectomy, because the increase of the survival rate resulting from lymphadenectomy will fall within the margin of statistical error.</p>

Laparoscopic management of borderline ovarian tumors; KBSMC experience / 대한산부인과학회지

OBJECTIVE: To evaluate feasibility and efficacy of laparoscopic management for borderline ovarian tumors. METHODS: From May 2005 to October 2007 in our institution, laparoscopic treatments were performed for 16 patients for borderline ovarian tumors. Through clinical records, the patients' age, parity, operating time, tumor diameter, length of hospital stay, change in hemoglobin level, intraoperative and postoperative complications, and recurrence were analyzed. RESULTS: The median age of the patients was 38 years (27-72 years), the median parity was 1 (0-3), and 6 patients were nulliparous., Eight patients were performed conservative surgery, and radical surgery was performed in the remainder. The median operating time was 90 minutes (50-305 minutes), the median hospital stay was 5 days (4-16 days), the median change of the hemoglobin level was 1.5 g/dL (0.2-4.5 g/dL), and the median diameter of the tumors was 8.5 cm. FIGO stage was Ia for 9 patients, Ib for 2, Ic for 4, and IIIc for the last one. Histopathological results showed mucinous tumor for 8 patients, serous tumor for 6, and mixed type and endometrioid tumor for each remaining. Laparoscopic pelvic and paraaortic lymphadenectomy were performed 4 patients. There was no upstaging by intraoperative cystic rupture. Neither laparoconversion nor intraoperative complication was noted. The median duration of follow-up was 20 months (3-53 months) and none showed recurrence. One of 8 patients who were treated conservatively obtained a baby by vaginal delivery in 32th postoperative month. CONCLUSION: This preliminary analysis demonstrated patients with borderline ovarian tumor can feasibly and efficiently undergo laparoscopic management.

Laparoscopic Myomectomy for Large Myomas

The aim of this study was to assess the feasibility and efficacy of laparoscopic myomectomy (LM) for large myomas. A subpopulation of 51 patients with myomas 8 cm or larger in diameter was selected from 155 patients who underwent LM at Kangbuk Samsung Hospital from July 2003 to November 2006. The mean age of the patients was 34.9+/-5.6 yr, mean parity was 0.6+/-0.9, and 8 patients had a previous operative history. The most common operative indication was a palpable abdominal mass (24 patients, 47%). The mean operating time was 85.6+/-38.9 min, and the mean diameter of the largest myoma was 9.3+/-1.8 cm. The mean change in hemoglobin concentration was 2.1+/-1.2 g/dL. Histopathological diagnosis included 49 patients of leiomyoma (96.1%) and 2 patients of leiomyoma with adenomyosis (3.9%). Postoperatively, a transfusion was done in 7 patients, and a case of subcutaneous emphysema was noted. None of the operations was switched to laparotomy. With the newly-developed screw and the port placement system that was modified from the Choi's 4-trocar method to obtain better surgical vision, LM of large myomas proved to be one of the efficient and feasible methods.

Clinical efficacy of laparoscopic myomectomy for 110 cases of various sized myomas / 대한산부인과학회지

OBJECTIVE: To assess the feasibility and clinical efficacy of laparoscopic myomectomy (LM). METHODS: We analyzed retrospectively the data for 110 LM preformed at Kangbuk Samsung Hospital between July 2003 and July 2006. We reviewed their clinical charts and the operative and anesthetic records, and analyzed data on the patients' age, parity, previous operative history, preoperative indication, the diameter of the largest myoma, operating time, number of the removed myoma, hospital stay, change of the hemoglobin concentration from preoperative to postoperative day 1, concomitant procedures, histopathological reports, and complications. RESULTS: The mean age of the patients was 35.7+/-5.8 years, the mean parity was 0.8+/-0.9, and 26 (23%) patients had a previous operative history. The most common operative indication was a palpable abdominal mass (46 patients, 41.9%), followed by chronic pelvic pain (32 patients, 29.0%), abnormal uterine bleeding (24 patients, 21.8%), urinary frequency (7 patients, 6.4%), and infertility (1 patient, 0.9%). The mean operating time was 82.9+/-30.8 minutes, and the mean diameter of the largest myoma was 7.1+/-2.3 cm. The heaviest of the removed myoma weighed 795 gm. The mean change of the hemoglobin concentration was 2.2+/-1.1 g/dL, and the mean hospital stay was 3.5+/-1.4 days. Postoperatively, transfusions were done 10% (11 cases) of patients, and 2 cases of paralytic ileus and a case of subcutaneous emphysema were noted. Conversion rate to laparotomy was 0.9% (1 case). CONCLUSION: LM for various sized myomas can be performed successfully and effectively by decreasing laparoconversion, if the surgical team and the laparoscopic surgeon are experienced and enhanced equipment is available.

Laparoscopic adnexal surgery for posthysterectomy patients / 대한산부인과학회지

OBJECTIVE: To evaluate the feasibility and effectiveness of laparoscopic adnexal surgery in posthysterectomy patients and review clinical characteristics including comparison of the adhesion score of left with that of right adnexal mass. METHODS: From February 2004 to January 2007, we reviewed the medical records of 23 post-hysterectomy patients who received laparoscopic adnexal surgery including age, parity, type of hysterectomy, operative indications, histopathological diagnosis, operating time, size of the adnexal mass, adhesion score, change in the hemoglobin level, hospital stay, and any complications. RESULTS: The median age of patients was 48 years (range 35-69 years), and median parity was 2 (0-3). The median operating time was 100 minutes (range 35-180 minutes), and the median size of the adnexal mass was 7.1 cm (range 4-12 cm). The median change in hemoglobin level was 1.8 g/dL (range 0.6-4.1 g/dL). The median hospital stay was 4 days (range 3-19 days). The adhesion score was significantly higher in the left adnexal mass than in the right adnexal mass. Histopathological diagnosis included 6 cases of mucinous cystadenoma, 6 cases of functional cyst, 4 cases of hydrosalpinx, 3 cases of serous cystadenoma, 1 case of fibrothecoma, 1 case of mucinous adenofibroma, 1 case of endometrioma, and 1 case of tubo-ovarian abscess. There were no intraoperative complications or conversion to laparotomy. One case of postoperative ileus was noted. CONCLUSION: The skilled laparoscopic surgeon is capable of achieving successful result by performing laparoscopic surgery primarily to patients with adnexal mass for posthysterectomy patients who are expected to suffer severe adhesion. In posthysterectomy patients, left adnexal mass has more extensive adhesion than right adnexal mass, and these finding was represented as a high adhesion score of left adnexal mass.