Preservation of autonomic nerves in laparoscopic total radical hysterectomy.

OBJECTIVES: The aim of this study was to evaluate the feasibility, complications, margin status, and functional outcome (on urinary and sexual functions) of nerve-sparing radical hysterectomy (NSRH) performed laparoscopically. METHODS: Patients with cervical carcinoma of stage Ia2 and Ib1 underwent laparoscopic NSRH along with pelvic lymphadenectomy. We performed the technique in simple comprehensible steps with anatomic delineation of the autonomic nerves and selective cutting of the uterine and cervical branches. RESULTS: Laparoscopic NSRH was feasible in 85.7% of patients. Mean operative time was 160 minutes and all 7 patients had clear surgical margins. There were no complications and no blood transfusions were required. The median hospital stay was 3 days. The median return time for normal bladder function was 2 days and none of them required catheterization beyond 2 weeks. The mean residual urine volume was <50 mL. Urodynamic studies performed at 3 weeks after the operation showed no impairment of maximum flow rate (maximal flow rate: 20 ± 2 mL). The postoperative results of sexual dysfunction were inconclusive. CONCLUSION: Understanding this technique and the knowledge of laparoscopic anatomy of pelvic autonomic nerves is important in both benign and malignant pelvic surgeries. These preliminary results indicate that nerve sparing is easier done laparoscopically and its results are comparable to that of conventional laparoscopic radical hysterectomy in terms of lateral margin status and lymph node yield. Whether quality of life can be benefited by L-NRSH technique and its long-term oncological sequelae need further evaluation.

Thoracolaparoscopy in the lateral position for esophageal cancer: the experience of a single institution with 112 consecutive patients.

BACKGROUND: Esophagectomy has been performed using a thoracoabdominal, transhiatal, or transthoracic approach. All these methods have an acknowledged high intra- and postoperative morbidity. The principle of minimally invasive esophagectomy is to perform the operation the same as by the open approach but through a smaller incision, thus reducing the operative trauma without compromising the principles of the operation. The authors report their experience with thoracoscopic esophagectomy performed for 112 patients in left lateral position. METHODS: Patients with resectable thoracic or gastroesophageal junction cancer and medically fit for a three-stage esophagectomy underwent thoracoscopic esophagectomy in left lateral position. The procedure was converted to open surgery for 2 (1.79%) of the 112 patients. RESULTS: Since June 2005, 112 patients have undergone thoracoscopic esophagectomy in left lateral position. Of these patients, 80 patients had middle-third esophageal cancer. The pathology of 100 patients showed squamous cell carcinoma. The average thoracoscopic operating time was 85 min (range, 40-120 min). The average blood loss was 200 ml, and the average number of harvested mediastinal nodes was 20. Postoperative morbidity occurred for 16 patients, with 8 patients (7.27%) experiencing respiratory complications. Postoperative mortality was experienced by three patients. The median follow-up period was 18 months. CONCLUSIONS: Thoracoscopic esophagectomy is surgically safe and oncologically adequate. Thoracoscopy for patients in the left lateral position does not require prolonged single-lung ventilation. The anatomic orientation in the left lateral position is the same as that for open surgery, reducing the learning curve for thoracic surgeons. The potential advantages and the morbidity trend of prone instead of left lateral thoracoscopic esophagectomy needs to be evaluated.

Robotic radical hysterectomy: applying principles of the laparoscopic Pune technique.

Minimal access surgery is an accepted treatment modality in cervical cancer. Despite the advantages of laparoscopy, the surgical technique of laparoscopic radical hysterectomy is not very commonly performed. Robotic surgery is an emerging field with rapid acceptance because of the 3-dimensional image, dexterity of instruments and autonomy of camera control. We report here our technique of performing robotic radical hysterectomy using the Da Vinci surgical system. Twenty patients with cervical cancer stage 1a1-1b2 underwent robotic radical hysterectomy since December 2009. The median duration of surgery was 122 min, and the average blood loss was 100 ml. Postoperative ureteric fistulas occurred in two patients and were managed by ureteric stenting. The median lymph node retrieval was 30 nodes (range 18-38). We compared our robotic results with our published data on laparoscopic radical hysterectomy (Pune technique). We were able to complete all 20 cases robotically with minimal morbidity, and could duplicate our laparoscopic steps in robotic radical hysterectomy.

Laparoscopic total radical hysterectomy by the Pune technique: our experience of 248 cases.

STUDY OBJECTIVE: To describe our experience and technique of total laparoscopic radical hysterectomy with pelvic lymphadenectomy, which is the largest single- institution study. DESIGN: Retrospective, nonrandomized study (Canadian Task Force classification II-2). SETTING: Private hospital. PATIENTS: Two hundred forty-eight patients with International Federation of Gynecology and Obstetrics stage IA2 (n = 32) and IB1 (n = 216) of cancer of the cervix. INTERVENTION: Total laparoscopic type III radical hysterectomy with bilateral pelvic lymphadenectomy was done. Simple repetitive steps were used to perform this surgery and develop an easily replicable technique. Harmonic Shears, bipolar coagulation, and vascular clips were used. Resection of the cardinal and uterosacral ligaments was performed with LigaSure (LigaSure Vessel Sealing System; Valleylab, Tyco Healthcare, Boulder, CO) or the Harmonic Shears (Ethicon Endo-Surgery, Inc., Cincinnati, OH). Pelvic lymph node dissection was done. MEASUREMENTS AND MAIN RESULTS: Histopathologically, there were 183 (73%) cases of squamous carcinoma, 52 (20%) adenocarcinomas, and 13 (5%) adenosquamous carcinomas. Four patients needing anterior exenteration because of bladder involvement were excluded from data analyses. The operation was performed entirely by laparoscopy in all patients and by the same surgical team. The patients' median age was 61 years. The median operative time was 92 minutes (range 65-120 minutes). The median number of resected pelvic nodes was 18. The median blood loss was 165 mL. The median length of stay was 3 days. All 15 intraoperative complications were tackled laparoscopically. No patients were converted to the open technique. There were no deaths in our series. Seventeen patients had complications within 2 months of surgery. Seven patients had recurrences after a median follow-up of 36 months. CONCLUSION: Our technique of total laparoscopic radical hysterectomy, developed over 248 cases, can be performed safely. It is an easily replicable technique. This procedure reduces the morbidity associated with abdominal radical hysterectomy. All of the complications can also be tackled laparoscopically, which does not further add to the morbidity.

Endoscopic thyroidectomy: Our technique.

UNLABELLED: Minimally invasive surgery is widely employed for the treatment of thyroid diseases. Several minimal access approaches to the thyroid gland have been described. The commonly performed surgeries have been endoscopic lobectomies. We have performed endoscopic total thyroidectomy by the anterior chest wall approach. In this study, we have described our technique and evaluated the feasibility and efficacy of this procedure. MATERIALS AND METHODS: From June 2005 to August 2006, 15 cases of endoscopic thyroidectomy were done at our institute. Five patients were male and 10 were female. Mean age was 45 years. (Range 23 to 71 years). Four patients had multinodular goiter and underwent near-total thyroidectomy; four patients had follicular adenoma and underwent hemithyroidectomy. Out of the seven patients of papillary carcinoma, four were low-risk and so a hemithyroidectomy was performed while three patients in the high risk group underwent total thyroidectomy. A detailed description of the surgical technique is provided. RESULTS: The mean nodule size was 48 mm (range 20-80 mm) and the mean operating time was 85 min (range 60-120 min). In all cases, the recurrent laryngeal nerve was identified and preserved intact, the superior and inferior parathyroids were also identified in all patients. No patients required conversion to an open cervicotomy. All patients were discharged the day after surgery. All thyroidectomies were completed successfully. No recurrent laryngeal nerve palsies or postoperative tetany occurred. The postoperative course was significantly less painful and all patients were satisfied with the cosmetic results. CONCLUSIONS: It is possible to remove large nodules and perform as well as total thyroidectomies using our endoscopic approach. It is a safe and effective technique in the hands of an appropriately trained surgeon. The patients get a cosmetic benefit without any morbidity.

Laparoscopic ureteroneocystostomy with psoas hitch.

BACKGROUND AND PURPOSE: Laparoscopic extravesical ureteroneocystostomy is an infrequently described technique. Our aim is to describe five cases where we used the intracorporeal freehand suturing technique successfully for performing laparoscopic extravesical transperitoneal ureteral reimplantation with psoas hitch. We describe the preliminary results of these cases. PATIENTS AND METHODS: We performed this surgery in five female patients. Two patients had a low ureterovaginal fistula after total laparoscopic hysterectomy. The other three patients had undergone laparoscopic radical hysterectomy. RESULTS: The average surgical time was 220 minutes. The average blood loss was 150 mL. The average stay was 3 days, and the average time to starting oral intake was 12 hours. No intraoperative or postoperative complications occurred. The urinary catheter was removed after 3 weeks and the double j stent after 6 weeks. Follow-up urography showed good clearance of the kidney and ureter. There was no reflux on the postoperative cystogram. CONCLUSION: Laparoscopic extravesical ureteroneocystostomy with intracorporeal freehand suturing technique and psoas hitch is a feasible procedure in females for managing ureterovaginal fistulas after laparoscopic gynecologic surgeries. The patients need not be subjected to open surgery because this complication can be repaired laparoscopically, thus minimizing the morbidity.

Laparoscopic pelvic exenteration for advanced pelvic cancers: a review of 16 cases.

OBJECTIVE: The aim of this study was to retrospectively evaluate, in a series of 16 consecutive patients, the technique, feasibility and oncological safety of laparoscopic anterior exenteration for locally advanced pelvic cancers. STUDY DESIGN: Since August 2003, 16 patients with locally advanced pelvic cancer were considered. All patients were in a good general condition, in the age group of 50-60 years of which 12 had cervical carcinoma and 4 had bladder carcinoma. RESULTS: The median operative time was 180 min. The mean number of harvested pelvic iliac nodes was 14. All margins were tumor-free. The median postoperative hospital stay was 3 days. Three patients had postoperative complications; two had subacute intestinal obstruction and one had ureteric leak. The median follow-up was 15 months. CONCLUSIONS: Our results have demonstrated the feasibility and oncological safety of performing anterior exenteration laparoscopically in advanced pelvic cancer patients with acceptable morbidity. Intermediate-term follow-up validates the adequacy of this procedure.