An objective experimental assessment of the learning curve for laparoscopic surgery: the example of pelvic and para-aortic lymph node dissection.

OBJECTIVES: To date the number of procedures required to become competent to perform new laparoscopic surgical techniques is not known. STUDY DESIGN: The pig model was chosen for assessment of the learning curve associated with an advanced laparoscopic procedure. A unilateral laparoscopic pelvic lymphadenectomy was performed by two residents and a laparoscopic para-aortic lymphadenectomy was performed by a fellow on a series of 20 pigs. The quality of the dissection was checked by immediate laparotomy by an independent observer. RESULTS: The operative objectives were: (a) There should be less than 5% residual lymph nodes. (b) The operating time should be less than 30 min for pelvic and less than 100 min for para-aortic lymphadenectomy. (c) Avoiding conversion because of complications. This target was achieved after 7 and 9 pigs respectively for pelvic lymphadenectomy and after 14 pigs for para-aortic lymphadenectomy. CONCLUSION: It is feasible to assess the learning curve of trainee surgeons while performing laparoscopic pelvic and para-aortic lymphadenectomy on pigs. A training programme such as this should prevent complications due to inexperience and should satisfy ethical and medico-legal considerations.

Accuracy and safety of laparoscopic lymphadenectomy: an experimental prospective randomized study.

INTRODUCTION: The goal of this study was to investigate the accuracy and safety of bilateral pelvic and paraaortic lymphadenectomy performed via transperitoneal laparoscopy (LS) compared to laparotomy (LT) in a porcine model. MATERIALS AND METHODS: Fifteen adult, female hogs underwent LS and 15 underwent LT. A complete pelvic and paraaortic lymphadenectomy was performed in each animal by an experienced surgeon. Lymph nodes were counted by a pathologist in each case. Operative times were reviewed and included all procedures performed. The intraoperative complications were noted. Four weeks after the lymphadenectomy, the animals underwent exploratory laparotomy, and intraperitoneal adhesions were quantified. RESULTS: Thirty animals were evaluable. The average total number of lymph nodes retrieved by LS was 16.9 +/- 3.8, which was not statistically (P = 0.77) different from 16.5 +/- 4.9 nodes in LT. The average operating time in LT was 60 +/- 16 min compared with 128 +/- 24 min in LS. Twenty-eight animals were evaluable for adhesion formation. The average adhesion scores observed in anterior abdominal wall (P = 0.0006), paraaortic (P = 0.0005), right (P = 0.015), and left (P = 0.0324) iliac areas after LS were uniformly lower than after LT. DISCUSSION: This study indicates that laparoscopic pelvic and paraaortic lymphadenectomy is a safe and effective procedure. The node yield is similar for both approaches. The transperitoneal laparoscopy pelvic and paraaortic lymphadenectomy may not induce the degree of adhesion formation associated with laparotomy.

[Endometrial cancer: total simple hysterectomy or radical hysterectomy? Abdominal or vaginal route?]. / Cancer de l'endomètre: hystérectomie totale simple ou hystérectomie élargie? Voie haute? Voie basse?

Total abdominal hysterectomy and bilateral salpingo-oophorectomy has long been the standard surgical treatment for endometrial cancer. Radical hysterectomy is not useful in stage I. in women with extreme obesity and medical risk factors, vaginal hysterectomy is recommended. Laparoscopy-assisted vaginal hysterectomy complete the oncologic treatment if lymphadenectomy is necessary.

[The advantage of an umbilical micro-laparotomy, "open laparoscopy", for laparoscopic surgery. Experimental study]. / Le bénéfice de la micro-laparotomie ombilicale "open laparoscopy" pour l'abord coelioscopique. Etude expérimentale.

This study was carried out to evaluate the respective safety of standard introduction of the umbilical trocar after insuflation of the abdomen through a veress needle, direct trocar insertion, and the open laparoscopy approach. Abdominal adhesion were induced by standardized peritoneal trauma in 60 New Zeland white female rabbits. Three weeks later, the animals were randomly assigned to one of three techniques: group 1: standard approach; group 2: direct trocar insertion; group 3: open laparoscopy. Twenty-four bowel injuries occurred in group 1, thirty nine in group 2, and six in group 3. The differences between groups were statistically significant (group 1 vs group 2: p = 0.03; group 3 vs group 1: p = 0.004; group 3 vs group 2: p = 0.0001). These findings favor the use of the open laparoscopy approach when abdominal adhesions are suspected. The standard approach is safer than the technique without pneumoperitoneum, but would require an endoscopic visualization of the umbilical trocar insertion to reduce the complication rate.

[Value and limits of complementary investigations in cases of toxoplasmosis seroconversion during pregnancy. A case report and review of the literature]. / Intérêt et limites des investigations complémentaires en cas de séroconversion toxoplasmique en cours de grossesse. A propos d'un cas et revue de la littérature.

We report a case of acute toxoplasmosis during the first trimester of pregnancy in which antenatal diagnosis was negative. Except for non-specific signs of liver failure, assessment by repeated ultrasound scans, testing of fetal blood for toxoplasmic specific antibodies and competitive PCR to isolate the parasite, had ruled out fetal infection. In spite of early treatment with spiramycin, and although the infant was assumed to be non-contaminated, severe hydrocephalus was noted at 3 and half months of life, arising soon after therapy had been stopped. This case focuses attention on the problem of the shortcomings of the diagnostic techniques currently used, and leads us to question our practical course of action. Several questions are thus raised: how reliable are indirect signs of fetal compromise, what is the real sensitivity of the PCR test and how useful are repeated amniocentesis and inoculation of the amniotic fluid to mice.

[Granulosa cell tumors: a case located in the broad ligament of the uterus with normal ovaries]. / Tumeur de la granulosa. A propos d' un cas de tumeur du ligament large avec ovaries normaux.

Granulosa cell tumours are relatively rare ovarian tumors. The incidence was 0.9 cases per 100,000 women per year. We describe a quite uncommon granulosa tumour found in the broad ligament. The patient was a 25-year-old, white woman, gravida 4, para 2. Surgical treatment was tumourectomy with homolateral salpingo-oophorectomy. From this observation, embryology, clinical and paraclinical aspects, treatment and prognosis of these tumours are reviewed.

[Bowel complications in gynecologic laparoscopic surgery and their immediate repair without laparotomy. Four cases]. / Complications digestives de la coeliochirurgie gynécologique et leur réparation immédiateà ventre fermé. A propos de quatre observations.

Laparoscopic surgical procedures are increasing throughout the world, and with this increase in its utilization, a renewed interest in its possible complications. We presented four case reports of bowels injuries and their repair by laparoscopy. We reviewed the literature and discuss common complications with suggestions to avoid such injuries and for management. We conclude that small and large bowel enterostomies can be repaired safely via the laparoscope with minimum morbidity in patients with a prepared bowel. More serious complications occur if visceral trauma is not handled immediately. There is no place for adopting a "wait and see" approach.

[Steinert's disease and pregnancy. A case report and recent literature]. / Maladie de Steinert et grossesse. A propos d'un cas et des données récentes de la littérature.

Steinert's disease or myotonic dystrophy is a heredo-degenerative neuroendocrinal dystrophy. It is an autosomal dominant disorder. The arising of a congenital myotonic dystrophy of one of the new-born children of the maternity hospital enabled to diagnose the Steinert's disease of his mother. A review of the international literature enabled us to recall its interactions with pregnancy. There is an aggravation of myotonia and multiple obstetric complications such as miscarriage, premature onset of labor, polyhydramnios, stillbirth, difficulties during the evacuation, atonic postpartum hemorrhage, anesthetic-accidents. The congenital variant of myotonic dystrophy (6 to 30% of the cases) is a severe disease with a high mortality. It is only seen in the offspring of mothers who themselves have myotonic dystrophy. The myotonic dystrophy gene has been isolated and the mutation-causing myotonic dystrophy was found to result from a series of trinucleotide (CTG) repeats located in the 3' untranslated region of the gene. The direct diagnosis is henceforth possible both on the fetus and parents. Steinert's disease and its association with pregnancy are rare, especially when the affected parent has hypogonadism. The diagnosis of the congenital form is difficult because of the mother is unaware of the disorder. Family and personal history may give hints: hydramnios, appearance delay and reduced fetal movements, and the association at birth of generalized hypotonia with neonatal respiratory distress.

[Delay of the formation of retroperitoneal fibrosis after lymphadenectomy. An experimental study]. / Délai de formation de la fibrose rétropéritonéale après lymphadénectomie. Etude expérimentale.

The goal of our study was to evaluate peritoneal and retroperitoneal healing and therefore to assess the optimal date for surgery after laparoscopic lymphadenectomy. A para-aortic lymphadenectomy was carried out in 5 groups of 5 New Zealand female rabbits. The perivascular cicatricial tissue was dissected after specific delay for each group (48 hours, 1 week, 2 weeks, 4 weeks, and 6 weeks). Peritoneal reconstruction was observed in 80% of the "48 h" group, and in 100% in the other groups (from 1 to 6 weeks). Vascular injury complicated dissection in 40% for the "1 week" group, in 80% for the "2 weeks" group, and in 20% for the "6 weeks" group. No vascular complication was observed in the "48 h" and "4 weeks" groups. The results of "1 week" and "2 weeks" were combined. The results of the "4 weeks" group were compared, with the Fisher test, to the results of a "1 week" and "2 weeks" combined group as well as to the results of the "six weeks" group. Four weeks seem to be the optimal date for a possible surgical excision after a laparoscopic lymphadenectomy.

[Celioscopic pelvic and para-aortic lymphadenectomy]. / Lymphadénectomie pelvienne et para-aortique coelioscopique.

Because small volume lymph node metastases are difficult to recognize despite modern imaging techniques and since staging laparoscopy is costly and leads to important patient discomfort, pelvic then para-aortic lymph node endoscopic dissection has been introduced for staging gynaecological cancers. Since 1988, we have performed 110 pelvic and 17 para-aortic lymph node dissections using this technique. Pava-aortic endoscopic biopsy is indicated for advanced cancer of the cervix and subrenal biopsy for cancer of the ovary. Pelvic node dissection alone is useful in early stage cancers of the uterus and in cancers of the endometrium as well as in urological indications.

[Proximal tubal recanalization by endoluminal laser probe. I. Anatomic results in the female rat]. / Recanalisation tubaire proximale par sonde laser endoluminale. I. Résultats anatomiques chez la rate.

To evaluate the cicatrization of the uterine horn after the recanalization by endoluminal laser probe, 50 white female rats of Wistar's race have been separated into two groups. The group 1 (nb = 10) had for aim to validated the procedure of obstruction. In group 2 (nb = 40), we performed the recanalization six weeks after the obstruction. Histologic samples were obtained 48 hours, 3 weeks and 6 weeks after treatment. In group 1, we found a complete obstruction in 70% of the cases, and a tight stenosis in 30% of the cases. In group 2, at 48 hour's control after the treatment by laser, we found a drill hole with a blackened look without parietal sequel in 80% of the cases. At 6 week's control, we found a normal lumen with a regeneration of the epithelioma in 85% of the cases. For energy deposition under 30 Joules, we found good results in 95% of the cases. Above 30 Joules, we always found bad results (5 cases on 5).

[Proximal tubular recanalization by endoluminal laser. II. Functional results in the female rabbit]. / Recanalisation tubaire proximale par sonde laser endoluminale. II. Résultats fonctionnels chez la lapine.

To evaluate the function of the fallopian tube after a recanalization by endoluminal laser probe, 34 mature female New Zealand white rabbits have been separated into two groups. The group 1 (nb = 12) had for aim to validate the procedure of obstruction. In group 2 (nb = 22), we performed the recanalization six weeks after the obstruction. The female rabbits underwent a fertilization six weeks after the laser treatment. The results have been appreciated by the ratio nidation/ovulation. In group 1, we valided the procedure of obstruction. In group 2 twelve rabbits on thirteen have been fecundated in the treated tube.