Endometriosis Resection Using Nerve Sparing Versus Non-nerve Sparing Surgical Techniques.

Introduction: Endometriosis is the condition in which there are ectopic endometrial tissues outside the uterine cavity. The use of nerve sparing technique has been well established in the field of oncology, leading to better quality of life following radical oncologic procedures without compromising on the long-term survival. The objective of this study is to compare the quality of life in terms of sexual function and urinary function in women undergoing nerve sparing surgeries for endometriosis and those undergoing non-nerve sparing surgeries. Material and Methods: Data of 51 patients operated for endometriosis at Galaxy Care Laparoscopic Institute, Pune, India between 1st January 2020 till 31st December 2020 were collected and analysed. We included patients in age group between 38 and 44 years in monogamous relationship, with moderate to severe endometriosis (Revised American Society of Reproductive Medicine r-ASRM score of 16 and above 5), being operated for hysterectomy along with ureterolysis and/or bowel resection (including shaving of rectal endometriosis, discoid resection, segmental resection), and excision of large ovarian endometriomas (> 3 cm size) with cul-de-sac obliteration. Results: The patients were evaluated for the following factors: age, parity, nature of surgery done, immediate intraoperative complications (bowel injury, bladder injury, ureteric injury), operative time in minutes, average blood loss, length of hospital stay, days to removal of foley's catheter and postoperative urinary and sexual function which were assessed on follow up visit and a 1-year follow up interview. We found that the urinary and sexual function in the group undergoing nerve sparing surgeries was significantly better than the patients undergoing non-nerve sparing surgeries. Conclusion: Laparoscopic nerve sparing approach for clearance of endometriosis has allowed better quality of life post surgery. Proper understanding and demonstration of pelvic neuroanatomy has made this approach feasible and achievable in carefully selected patients.

Anatomical Description of Anterior Parametrium: A Probable Answer to Pelvic Recurrence Following Radical Hysterectomy.

A prospective analysis of a retrospective data of patients with cervix carcinoma treated by minimal invasive surgery at high-volume gynecology oncology center analyzing that minimal access surgery is an acceptable treatment modality in cervix carcinoma. The study included 423 patients who underwent laparoscopic/robotic radical hysterectomy after pre-operative evaluation after taking their consent and obtaining ethical approval from the IRB. Post-operatively, patients were followed up at regular intervals for clinical examination and ultrasonography for a median range of 36 months. A PET scan was done only if there was any suspicious finding on clinical examination or ultrasonography. Patients with parametrial involvement, positive vaginal margins, and nodal involvement were treated with chemotherapy/radiotherapy. Four hundred twenty-three patients of cervix carcinoma were treated with minimal access surgery. Average duration of surgeries was 92 min. Median range of duration of post-operative follow-up was 36 months. None of the patients had positive resection margins indicating adequate parametrectomy with complete oncological clearance. On post-operative follow-up, only 2 patients had vaginal recurrence which is comparable to that observed in open surgery and no pelvic recurrence. With the understanding of the anatomical landmarks of the anterior parametrium and development of skills for adequate oncological clearance, minimal access surgery should be the preferred surgical modality in carcinoma of the cervix.

Feasibility of transthoracic esophagectomy with a next-generation surgical robot.

Robot-assisted minimal access surgery (MAS), compared with conventional MAS, has shown a number of benefits across several therapeutic indications but its use for transthoracic esophagectomy (TTE) requires further evaluation. Here, we report the first-in-human series of major esophageal resections performed using a next-generation tele-operated robotic surgical system in a single center. Robot-assisted TTE was performed using the Versius Surgical System by a single surgeon to assess the robotic system's ability to achieve tumor clearance (measured by R0 resection rates) whilst reducing anastomotic leakage rates. Intra- and post-operative outcomes such as median operative time, length of hospitalization, intra-operative blood loss, and the number of complications were also assessed. Fifty-seven patients underwent robot-assisted TTE between August 2019 and June 2021. All procedures were completed successfully with no unplanned conversions to alternative surgical methods. Estimated blood loss was minimal, and no adverse events, complications or deaths were reported. Our experience with the Versius Surgical System demonstrates its safe adoption and implementation for TTE.

Learning Curve of Total Laparoscopic Hysterectomy for a Resident in a High-Volume Resident Training Setup.

Study Objective: To evaluate the resident learning curve, demographic and comparative analysis of total laparoscopic hysterectomy. Design: This retrospective observational study was conducted in a high-volume resident training setup. Setting: Tertiary care center is used in the study. Materials and Methods: Eight hundred and one total laparoscopic hysterectomy patients operated by the residents between July 2013 and June 2019 were evaluated with respect to the learning curve, duplication of the steps, the results in terms of intra- and postoperative complications and the time taken for the surgery. Surgeries were assigned as per the institutional inclusion criteria for the residents. The fellowship program enrolled six residents per year for training period of 1 year. The residents initially performed ten simple cases under the supervision of the director followed by ten cases which were performed independently, and based on their learning curve, they then performed advanced cases independently. Results: TLH was successfully performed in all women by surgical residents in training. The surgical time was 61-120 min in majority (49.3%). 2.99% had intra-operative complications while 7.61% had postoperative complications which were identified and managed. All women recovered uneventfully. Conclusions: Dedicated teaching staff, uniform surgical protocols and high-volume centers contribute to the safety of TLH.

The Future of Adhesion Prophylaxis Trials in Abdominal Surgery: An Expert Global Consensus.

Postoperative adhesions represent a frequent complication of abdominal surgery. Adhesions can result from infection, ischemia, and foreign body reaction, but commonly develop after any surgical procedure. The morbidity caused by adhesions affects quality of life and, therefore, it is paramount to continue to raise awareness and scientific recognition of the burden of adhesions in healthcare and clinical research. This 2021 Global Expert Consensus Group worked together to produce consented statements to guide future clinical research trials and advise regulatory authorities. It is critical to harmonize the expectations of research, to both develop and bring to market improved anti-adhesion therapies, with the ultimate, shared goal of improved patient outcomes.

Colorectal cancer surgery: by Cambridge Medical Robotics Versius Surgical Robot System-a single-institution study. Our experience.

With the previous experiences in performing laparoscopic for over a period of 15 years and da Vinci colorectal surgeries from 2010 to 2013, we started operating using the Cambridge Medical Robotics (CMR) Versius Surgical Robot System. The aim of the study is a prospective analysis and evaluation of short-term results of consecutive patients to study the technical feasibility and oncological outcome of robot-assisted low anterior resection (LAR) and ultralow anterior resection (ULAR), using the CMR Versius Surgical Robot System. This study was conducted at single minimal access surgery institute. 31 patients with colorectal adenocarcinoma underwent robot-assisted LAR and ULAR between August 2019 and March 2020. Patient characteristics, perioperative parameters and complications were evaluated. Surgical and pathological outcomes such as quality of Total Mesorectal Excision (TME), free circumferential resection margins and number of lymph nodes dissected were also evaluated. Of 31 patients, 23 were men and 8 women, with mean age of 55.6 years. The mean robotic operative time was 51 min and the mean blood loss was 55 ml. The mean robot docking and undocking time was 17 min and 5 min, respectively. The mean hospital stay was 7 days. The longitudinal and circumferential resection margins were negative in all patients. Histopathological reports of 27 among 31 patients showed complete TME. Splenic flexure of colon mobilization was done laparoscopically. We feel that Versius robot has the qualities in terms of dexterity, vision and intuitive movements, and to translate this technical ability into oncological safety.

Feasibility of robotic radical hysterectomy (RRH) with a new robotic system. Experience at Galaxy Care Laparoscopy Institute.

The main objective of this study was to assess in a series of 30 patients, the feasibility, oncological safety and efficacy of radical hysterectomy by a new robotic system. Prospective study design. Galaxy Care Laparoscopy Institute and Multispeciality Hospital. We performed Robotic Radical Hysterectomy in patients from August 2019 through February 2020. All the surgeries were performed by a single surgeon (Puntambekar S). Since August 2019, 30 patients with early cervical cancer/endometrial cancer were selected for radical hysterectomy. All patients were in good general condition with controlled medical comorbidities. The mean operative time was 104 min, with mean total lymph node yield of 24.7. The average blood loss was 60 ml and the hospital stay was 2.1 days, and majority of the patients were catheter free by 1 week. Two patients developed uretero-vaginal fistula on the 8th day of surgery. One was managed with Double J stenting and in the other we did laparoscopic ureteroneocystostomy. Our study has demonstrated the feasibility, safety and efficacy of RRH by the Versius robotic systems.

Single-Centre Experience of Doing Safe Total Laparoscopic Hysterectomy: Retrospective Analysis of 1200 Cases.

STUDY OBJECTIVE: Assessment of safety and feasibility of total laparoscopic hysterectomy in a high-volume tertiary care centre. DESIGN: Retrospective study design. SETTING: Tertiary care centre: Galaxy care Hospital, Pune, India. MATERIALS AND METHODS: This is a retrospective observational study conducted in a tertiary care resident training hospital in Pune which is a high-volume teaching hospital. 1200 total laparoscopic hysterectomy patients between July 2013 and June 2019 operated by a group of trained surgeons were analysed, and parameters, namely demography, indication of surgery, surgical time, intra-operative blood loss, post-operative complications, duration of hospital stay, discharge and follow-up, were studied. RESULTS: A total of 1200 women who underwent total laparoscopic hysterectomy for various indications were included in the study. TLH was successfully performed in all women. Mean age of women was 45 years. 72.00% had a BMI between 18.5 and 24.9, 16.08% had a BMI between 25 and 29.9, 3.92% had a BMI of > 29.9 while 8% had a BMI < 18.5. Indications for surgery included uterine fibroid (33.08%), adenomyosis (22.25%), endometrial hyperplasia (14.33%), endometrial polyp (7%), endometriosis (3.33%), postmenopausal bleeding (9.25%), chronic PID (5.25%), prolapse (4.25%) and risk reduction surgery in 1.25%. 2.00% had intra-operative complications while 7.58% had post-operative complications which were identified and managed successfully. CONCLUSIONS: Advances and innovation in equipment, energy sources and surgical training have made TLH a well-tolerated and efficient surgery. Irrespective of the previous morbidity, pathology and uterine size, TLH is a duplicable and safe in a well-trained high-volume centre.

Distribution of lymph node metastases in esophageal carcinoma [TIGER study]: study protocol of a multinational observational study.

BACKGROUND: An important parameter for survival in patients with esophageal carcinoma is lymph node status. The distribution of lymph node metastases depends on tumor characteristics such as tumor location, histology, invasion depth, and on neoadjuvant treatment. The exact distribution is unknown. Neoadjuvant treatment and surgical strategy depends on the distribution pattern of nodal metastases but consensus on the extent of lymphadenectomy has not been reached. The aim of this study is to determine the distribution of lymph node metastases in patients with resectable esophageal or gastro-esophageal junction carcinoma in whom a transthoracic esophagectomy with a 2- or 3-field lymphadenectomy is performed. This can be the foundation for a uniform worldwide staging system and establishment of the optimal surgical strategy for esophageal cancer patients. METHODS: The TIGER study is an international observational cohort study with 50 participating centers. Patients with a resectable esophageal or gastro-esophageal junction carcinoma in whom a transthoracic esophagectomy with a 2- or 3-field lymphadenectomy is performed in participating centers will be included. All lymph node stations will be excised and separately individually analyzed by pathological examination. The aim is to include 5000 patients. The primary endpoint is the distribution of lymph node metastases in esophageal and esophago-gastric junction carcinoma specimens following transthoracic esophagectomy with at least 2-field lymphadenectomy in relation to tumor histology, tumor location, invasion depth, number of lymph nodes and lymph node metastases, pre-operative diagnostics, neo-adjuvant therapy and (disease free) survival. DISCUSSION: The TIGER study will provide a roadmap of the location of lymph node metastases in relation to tumor histology, tumor location, invasion depth, number of lymph nodes and lymph node metastases, pre-operative diagnostics, neo-adjuvant therapy and survival. Patient-tailored treatment can be developed based on these results, such as the optimal radiation field and extent of lymphadenectomy based on the primary tumor characteristics. TRIAL REGISTRATION: NCT03222895 , date of registration: July 19th, 2017.

Laparoscopic Intracorporeal Pancreaticogastrostomy in Total Laparoscopic Pancreaticoduodenectomy-A Novel Anastomotic Technique.

Novel pancreaticogastric anastomosis technique in laparoscopic pancreaticoduodenectomy which is simple, feasible to perform, provides secure fixation between stomach and pancreas. The aim of our article is to describe our technique of intracorporeal pancreaticogastrostomy as a promising approach for future widespread application.

Novel Anastomotic Technique for Uterine Transplant Using Utero-ovarian Veins for Venous Drainage and Internal Iliac Arteries for Perfusion in Two Laparoscopically Harvested Uteri.

STUDY OBJECTIVE: To evaluate 2 cases of uterine transplant surgery that used utero-ovarian veins as outflow channels, internal iliac arteries for perfusion, and the organ harvest surgery performed laparoscopically. DESIGN: Case study (Canadian Task Force Classification III). SETTING: An urban, private, tertiary care hospital. PATIENTS: Two patients, ages 30 and 24years, diagnosed with absolute uterine factor infertility secondary to Mayer-Rokitansky-Küster-Hauser syndrome underwent related living donor uterine transplants; donors were their mothers with normal menses. INTERVENTIONS: Retrieval of organs through minilaparotomy and laparoscopic harvest of donor internal iliac arteries and ovarian veins. MEASUREMENTS AND MAIN RESULTS: Anastomosis was completed with bilateral donor internal iliac arteries to recipient internal iliac arteries in an end-to-end manner and with bilateral donor ovarian veins to recipient external iliac veins in an end-to-side manner. The lengths of utero-ovarian veins of both donors were 11 and 11cm on both sides; the lengths of the internal iliac arteries of both donors were 10 and 7.5cm on the left side and 10 and 6cm on the right side. The operative times for harvest surgery, bench surgery and transplant surgery were 2:40 and 3:20 hours, 34:32 and 33:30 min and 4:00 and 4:30 hours respectively for recipients 1 and 2. Daily postoperative uterine Doppler was completed through day 8 and then every other day and showed good intrauterine blood flow (i.e., low resistance arcuate vessel flow; resistance index < .5). Cervical biopsies on postoperative days 7 and 14 showed no evidence of rejection in either recipient. Both recipients started menstruating within 2 months of surgery. CONCLUSION: By using ovarian veins as outflow channels, the challenges involved in dissection along the internal iliac vein are avoided, and harvesting the donor internal iliac artery reduces the tension on vascular anastomosis. The selection of vessels to be harvested could make the technique reproducible, although larger studies are warranted to confirm results.

Evaluation of 5-year results of laparoscopic transhiatal oesophagectomy as a single-centre experience.

INTRODUCTION: Minimal Invasive Surgery of oesophageal cancers is gaining popularity. We have published our Thoracoscopic Esophagectomy results. The present study focuses on our expertise of TransHiatal Esophagectomy. MATERIALS AND METHODS: 287 patients underwent Esophagectomies for Cancer of Esophagus at Galaxy Care Laparoscopy Institute from January 2010 to December 2014 after thorough assesment. Out of these, 81 patients underwent laparoscopic trans hiatal esophagectomies. Their charts were reviewed retrospectively for intraoperative and postoperative results. The median follow up was 28 months. RESULTS: Out of 81 patients,76 patients had R0 resection and 5 had R1. The average lymphnode yield was 20,average survival was 28months. 3 patients had local recurrence,18 had regional recurrence and 30 had distant recurrence. Average operating time was 140 min,mean blood loss was 80 ml. Average Post-operative ICU stay was 1 day and hospital stay 7 days. CONCLUSION: Classic THE has limitations which can be overcome by the use of laparoscopic techniques. Laparoscopic approach for THE has better magnified vision facilitating better clearance under vision. Hence we recommend laparoscopic technique for THE to minimize morbidity and improve oncologic results.

Surgical pelvic anatomy in gynecologic oncology.

Laparoscopy, with its many advantages, has revolutionized the field of pelvic surgery and enabled surgeons to gain a far greater understanding of pelvic anatomy. As technology evolves, our understanding is continuously improving. This article is a tribute to the anatomy of the pelvis, which itself has resisted evolutionary changes and remained the same, whereas our understanding of how to view and approach various organ structures has evolved.

Laparoscopic-Assisted Uterus Retrieval From Live Organ Donors for Uterine Transplant: Our Experience of Two Patients.

STUDY OBJECTIVE: To report the first ever laparoscopic-assisted live donor uterus retrieval in 2 patients for uterus transplant. DESIGN: Case study (Canadian Task Force classification III). SETTING: Galaxy CARE Laparoscopy Institute, Pune, India. PATIENTS: Two patients with absolute uterine factor infertility with their mothers as donors. INTERVENTIONS: In vitro fertilization and uterine transplant. MEASUREMENTS AND MAIN RESULTS: A 12-member team was formed, and approval for transplant was obtained from the institutional review board. Pretransplant, in vitro fertilization for both patients was done. Two consecutive uterine transplants were done on 2 successive days. Vessels were harvested laparoscopically in both donors. Uterus and harvested vessels were retrieved by a small abdominal incision to prevent injury and infection. The uterus was transplanted in the recipients by end to side anastomosis of the harvested vessels to external iliac vessels, followed by anchoring of supports of the donor uterus to those of the recipients. Surgical intra- and postoperative parameters, postoperative investigations, and follow-up data of 6 months were measured. Operative time for laparoscopic donor surgery was 4 hours. Bench surgery took 45 minutes. Recipient surgery time was 4 hours. There were no intraoperative or immediate postoperative complications. Both the recipients started menstruating after 34 days and 48 days, respectively, and have had 6 cycles of menses at regular intervals. Uterine artery Doppler showed good flow in both patients. Hysteroscopy-guided cervical biopsies were used as a method of surveillance of graft rejection after uterine transplant. Office hysteroscopy was done after 2 months in both patients, and hysteroscopy-guided endometrial and cervical biopsies were taken. Minimal slough was seen on the endometrium in the patient with Mayer-Rokitansky-Küster-Hauser syndrome, which was removed. Repeat hysteroscopy after 10 days showed a healthy endometrium. CONCLUSIONS: Laparoscopic-assisted uterus donor retrieval is feasible and affords all the advantages of a minimally invasive technique, thereby reducing the morbidity of the procedure. It helps in better dissection of the vessels, shortens the operative time, and helps to minimize tissue handling of the harvested uterus and vessels.

Laparoscopic-Assisted Uterus Retrieval From Live Organ Donors for Uterine Transplant.

STUDY OBJECTIVE: The authors present the first ever laparoscopic-assisted uterus retrieval in a live donor for uterus transplant. DESIGN: A step-by-step surgical demonstration. SETTING: Galaxy CARE Laparoscopy Institute, Pune, India. PATIENTS: Two patients, ages 21 and 26 years, with Mayer-Rokitansky-Küster-Hauser syndrome and Asherman syndrome, respectively, with their mothers as donors. INTERVENTIONS: A 12-member team was formed. After a review of the available literature on uterine transplant, a protocol was formulated and submitted to the Institutional Review Board (IRB). Approval from the Institutional Review Board was obtained. Thorough screening of the candidates was done. Two consecutive uterine transplants were done on 2 successive days. Vessels were harvested laparoscopically in both donors. Uterus was retrieved through a small abdominal incision, to prevent any injury to the uterus and harvested vessels. Uterus was transplanted in the recipients by end-to-side anastomosis of the harvested vessels to the external iliac vessels, followed by anchoring of supports of the donor uterus to those of the recipients. MEASUREMENTS AND MAIN RESULTS: Surgical intra- and postoperative parameters, postoperative investigations, and follow-up data of 4 months. The operative time for laparoscopic donor surgery was 4 hours. Bench surgery took 45 minutes. The recipient surgery was completed in 4 hours. There were no intraoperative or immediate postoperative complications. Both recipients started menstruating after 34 days and 48 days, respectively, and have had 3 cycles of menses at regular intervals to date. After discharge, follow-up cervical biopsies at 3 weekly intervals showed no signs of rejection. Uterine artery Doppler ultrasound showed good flow in both patients. CONCLUSION: Laparoscopic-assisted donor retrieval is feasible and affords all advantages of a minimally invasive technique. It helps in better dissection of vessels, shortens the operative time, and helps minimize tissue handling, thereby reducing the morbidity of the procedure.

Technical Feasibility and Short-Term Outcome of Intracorporeal Hand-Sewn Esophagojejunostomy After Laparoscopic Total Gastrectomy: Our Experience.

The purpose of this study was to demonstrate the safety and technical feasibility of intracorporeal hand-sewn esophagojejunostomy after laparoscopic total gastrectomy. Laparoscopic total gastrectomy (LTG) is a technically challenging procedure, especially for esophagojejunal anastomosis (EJA). Various techniques have been described to overcome these difficulties using staplers with variable results. We report successfully performed complete intracorporeal hand-sewn EJA after LTG. The perioperative clinical data and short-term outcomes for 30 patients who underwent LTG using hand-sewn EJA for gastric cancer between 2013 and 2015 have been retrospectively reviewed. The mean age was 49.9 years; 64 % of patients were male and 36 % were female. The mean body mass index (kg/m2) was 22.4, and the mean American Society of Anesthesiologists (ASA) score was 1.4. Eleven patients had co-morbidities, and six patients had previous abdominal operations. The mean operative time, time for EJA, and blood loss was 136.9 min, 13.25 min, and 166 ml, respectively. The conversion rate was nil. The mean time for the first oral feeding and mean hospital stay was 8.3 and 9.8 days respectively. The postoperative complications were found in 16 % of patients with one case of 30-day mortality because of lobar pneumonia. There were three cases of anastomotic stenosis; however, no leakage was identified both clinically and radiologically. Complete intracorporeal hand-sewn EJA is a safe and feasible technique in the hands of experienced surgeons that can be considered as an alternative cost-effective method when performing LTG.

Management of Large Size MNGs and STNs Using 3D Endoscopic Technique: a Review of 10 Cases.

The role of endoscopic thyroidectomy has shown clear cosmetic benefits in the past. In this current study of 10 patients, we have tried to highlight the importance and benefits of 3D endoscopy in the management of large size multinodular goitres (MNGs) and solitary thyroid nodules (STNs). From March 2014 to July 2014, patients having a large volume of thyroid (>70 cc for one lobe) and nodule size (>6 cm) were enrolled for this study. A total of 10 patients underwent the procedure using the Karl Storz(TM) 3D endoscope system. Out of the 10 patients, 9 were females and 1 was male who underwent total, subtotal, and hemithyroidectomy. Three out of 10 turned out to be malignant for whom completion thyroidectomies were done endoscopically. The average blood loss was 29.5 cc and the mean operative time was 72 min. The average thyroid specimen volume was 115.4 cc with an average nodule size of 6.7 cm. Patients were discharged on the first post-operative day except one on the second post-op day. Post-operative scar was evaluated on the 14th day. 3D endoscopic thyroidectomy is definitely a step ahead in the management of large size MNGs and STNs. It gives excellent depth perception and magnification which helps in identification and preservation of important nerves and vessels which ensures safe removal of the thyroid from its bed.

Laparoscopic Management of Hilar Cholangiocarcinoma: a Case Report.

The only option for cure of Klatskin's tumour is surgical excision. The radicality of the procedure is determined by the extent of the tumour and functional parameters of the patient. Complete laparoscopic resection of hilar cholangiocarcinoma with biliary reconstruction is a challenging procedure. The main aim is to achieve pathological negative margins, complete lymph node retrieval and enterobiliary bypass. We present a case report of a patient with hilar cholangiocarcinoma managed laparoscopically. The nodal yield was nine. On 6-month follow-up, the patient was symptom free. The main aim is to study the feasibility of performing this complex procedure completely laparoscopically.

Our Experience of Laparoscopic Anterior Exenteration in Locally Advanced Cervical Carcinoma.

STUDY OBJECTIVE: To show the feasibility, technique, and results of laparoscopic anterior exenteration in selected patients. DESIGN: A retrospective cohort study. SETTING: Galaxy Care Laparoscopy Institute, Pune, India. PATIENTS: Seventy-four of 85 patients who underwent laparoscopic anterior exenteration for stage IVA carcinoma of the cervix from January 2005 to January 2015 were analyzed; the median follow-up was 30 months. Contrast-enhanced computed tomographic imaging of the abdomen and pelvis was performed for all patients. INTERVENTIONS: The same surgeon and team performed all the operations for uniformity in 10 operative steps. MEASUREMENTS AND MAIN RESULTS: The mean operative time was 180 minutes, and the mean blood loss was 160 mL. The mean hospital stay was 6 days. The average number of lymph nodes removed was 21.4. Surgical margins were negative in all patients. Forty-two patients had positive lymph nodes. Chemoradiation was given to those with positive lymph nodes. Perioperative complications occurred in 15 (20.27%) patients including deep vein thrombosis, urinary tract infection, ureterosigmoid leak (n = 2/74), and so on. Positron emission tomographic imaging and computed tomographic scanning were performed at 6 months after surgery and 6 months after adjuvant therapy in those with positive lymph nodes. There was no immediate postoperative mortality. The overall survival rate at 5 years was 25%. CONCLUSION: Laparoscopic anterior exenteration is feasible in cases of advanced carcinoma of the cervix. Results have shown that in selected patients this procedure is associated with good long-term survival.

Fascial Anatomy and Its Relevance in Safe Laparoscopic Hysterectomy.

STUDY OBJECTIVE: To demonstrate the importance of being familiar with the anatomy of the endopelvic fascia as seen by laparoscopy to perform safe laparoscopic hysterectomies. DESIGN: Combination of surgical videos and design diagrams. SETTING: Compiled high-definition surgical videos from the Galaxy Care Laparoscopy Institute, Pune, India. These videos clearly demonstrate the anatomy of the endopelvic fascia and describe tips to avoid damage to the major structures, including the major vessels, ureter, bowel, bladder, and endopelvic fascia. The laparoscopic view of the anatomy with the current camera system is an excellent tool to demonstrate and teach pelvic anatomy, which can be applied to surgical principles in difficult benign and oncological cases. INTERVENTION: We used a total laparoscopic approach to demonstrate the fasciae that were seen during various types of hysterectomies. The video shows the following: (1) the posterior leaf of the broad ligament was opened until it reached the apex of the uterosacral ligament; (2) the anterior leaf of broad ligament was opened until it reached the vesico-uterine peritoneal reflection; (3) the principles of bladder dissection; (4) the pubocervico-vesical fascia and its relevance to bladder dissection; (5) the relevance of the anatomy of the uterine artery, vein, and ureter with endopelvic fascia within the leaves of the broad ligament; (6) Denonvillier's fascia dissection technique for dissection of the rectum away from the vagina; (7) the anatomy of the vesicocervical ligaments, forming the ureteric tunnel; (8) the dissection principles of lateralizing the ureter in the retrovesical region; (9) the endopelvic fascia reflection, which continued caudally, covering the pelvic floor; and (10) the relevance of the anatomy of the endopelvic fascia and the stress urinary incontinence treatment technique. CONCLUSION: Understanding the anatomy of the fasciae of the pelvis helps to create avascular planes and is crucial for performing safe hysterectomies.