[Serum amyloid A as an effective marker for the assessment of surgical trauma and risk of post-operative complications]. / Sérový amyloid A jako efektivní marker stupne operacní záteze a rizika komplikací.

OBJECTIVE: To analyze relations among acute phase reactants in a group of 40 women operated for uterine myom by laparoscopy and open surgery. DESIGN: Prospective study. METHODS: Plasma concentrations of C-reactive protein (CRP), serum amyloid A (SAA) and interleukin 6 (IL-6) were measured together with leukocytes in blood before operation, 24 and 72 hours post operation, respectively. RESULTS: Leukocytes and IL-6 displayed minimal response and decreased quickly after operation to preoperative levels. Concentrations of CRP and SAA remained increased after operation. There were no relationships between leukocytes and acute phase reactants. Normal leukocytes 72 hours post operation were found in 1/3 of women with increased at least one acute phase reactants and in 1/4 of women with increased at least two markers. Typ of surgery, surgical stress and length of surgery were related to the concentration of CRP, IL-6 and SAA. CONCLUSION: Changes in SAA 24 hours after operation are similar to CRP and IL-6. Surgical stress, length of operation and possible risk 72 hours after operation are best predicted by CRP and SAA (at that time IL-6 and leukocytes are practically normal). Maximal increase was found for SAA concentrations. Thus SAA seems to be suitable marker of early postoperative complications.

Pregnancy outcomes and deliveries following laparoscopic transsection of uterine vessels: a pilot study.

OBJECTIVE: To assess pregnancy outcomes and deliveries after laparoscopic uterine artery transsection (LTUV) in symptomatic women with fibroids. SETTING: Department of Obstetrics and Gynecology, Endoscopic Training Center, Baby Friendly Hospital, Kladno, Czech Republic. DESIGN: One hundred and fifty three patients underwent laparoscopic transsection of uterine vessels during a 4-year period. RESULTS: Nine of the 21 women desiring pregnancy conceived spontaneously and one after anovulation treatment. The average age of the women was 32.4 years, and the range was 26-39 years. Two women had vaginal delivery at term and one delivered vaginally at 31 weeks secondary to premature preterm rupture of membrane (PROM). Four others delivered at term by cesarean section. One woman with placenta previa was delivered by cesarean section 3 weeks before term. Mean birth weight was 3199 g (range 1710-3910 g). One spontaneous abortion was reported in the first trimester of pregnancy. One case of undesired pregnancy occurred. An extrauterine pregnancy was reported in this woman. CONCLUSION: LTUV is a minimally invasive operative procedure, that preserves the uterus and ovarian blood supply and allows for the achievement of pregnancy in women with symptomatic fibroids. Fetal growth and umbilical Doppler findings remained normal in all cases. An increased risk for preterm delivery and cesarean section was found in this small series.

[Fistula as a complication of pelvic actinomycosis--two case reports]. / Fistula jako komplikace pánevní aktinomykózy--2 kazuistiky.

OBJECTIVE: The presentation of two unusual cases of pelvic actinomycosis. SUBJECT: Case reports. SETTINGS: Department of Obstetrics and Gynecology, Hospital Kladno. SUBJECT AND METHOD: The observation of two cases of pelvic actinomycosis. These cases were complicated by the abdominal wall fistula in one case and vaginal fistula in the other. CONCLUSION: Actinomycosis is a chronic disease with tendency to progress per continuitatem into neighbouring tissues and with tendency to formation of fistulas. Two less common localisations of progress of the disease are described; it means the abdominal wall and vagina. In spite of a more advanced stadium, if adequately treated, a recovery ad integrum is common.

Laparoscopic uterine artery dissection in an undiagnosed endometrial stromal sarcoma. Case report.

We present a case of a 24-year-old woman, gravida 0, with menometrorrhagia and pelvic pain. A uterine hemorrhagic fibroid was diagnosed after ultrasound and magnetic resonance imaging (MRI). The endometrial biopsy was negative for malignancy. Laparoscopic sentinel lymph node sampling, lavage, and myometrial biopsy with negative results were performed before dissection of the uterine vessels. The final diagnosis of endometrial stromal sarcoma was made by myomectomy and hysterectomy one year later. This case should demonstrate the difficulty of making the right diagnosis of sarcoma before laparoscopic dissection of uterine vessels in patients with symptomatic fibroids.

Uterine necrosis after laparoscopic uterine vessel dissection for symptomatic fibroid--a case report.

Laparoscopic dissection of uterine vessels is a new minimally invasive method to treat symptomatic fibroids. A potential complication of uterine artery dissection is uterine necrosis. A woman with a large intramural fibroid underwent laparoscopic dissection of the uterine vessels using ultrasonic activated shears and three months later developed focal uterine necrosis requiring exploratory laparotomy and supracervical hysterectomy. Although uterine artery coagulation and dissection are procedures with a low reported rate of complications, uterine fibroid or focal uterine necrosis can occur.

Midterm follow-up study of laparoscopic dissection of uterine vessels for surgical treatment of symptomatic fibroids.

BACKGROUND: This study aimed to assess laparoscopic dissection of uterine vessels (LDUV) for symptomatic fibroids in women. METHODS: A total of 69 women entered the study between March 2000 and June 2003. In this case series, 68 consecutive women underwent LDUV using ultrasonically activated sheers or electrosurgery for the treatment of fibroids over 3 years (median follow-up period, 14.5 months). Ultrasound or magnetic resonance imaging was carried out 3, 6, 12, 24, and 36 months after treatment. The tissue markers, gonadotropin, and estrogen levels were studied postoperatively. RESULTS: Almost all the patients (98.5%) had a successful LDUV with a low rate (7.3%) of postoperative complications. The time of surgery ranged from 15 to 50 min (mean, 30.8 min). The blood loss was minimal (mean, 14.7 ml), and the hospital stay was 2.4 days. Symptom improvement (menorrhagia or dysmenorrhoea) was 93.2%, and the average reduction in the dominant myoma was 57.8% during a follow-up period longer than 12 months. All the patients with anemia had normal red cell counts after 3 months. CONCLUSIONS: Uterine volume and the dominant fibroid were significantly reduced and symptoms were improved by LDUV. The laparoscopic procedure is associated with insignificant tissue damage and normal gonadotropin and estrogen levels.

Laparoscopically assisted modified radical vaginal hysterectomy (type II) with pelvic lymphadenectomy: ultrasonic operative technique.

OBJECTIVE: The aim of this study was to incorporate an ultrasonic operative laparoscopic technique to complete a type II laparoscopically-assisted modified radical vaginal hysterectomy (LARVH) and pelvic lymph node dissection (PLND) in early cervical cancer. METHODS AND MATERIALS: LARVH type II and PLND using a laparoscopic ultrasonic operative technique and conventional vaginal surgery were indicated in five cases of early cervical cancer (IA2). RESULTS: Complete pelvic lymphadenectomy and the laparoscopic phase of modified radical vaginal hysterectomy were successfully performed using ultrasonic instruments in all women. Uterine artery and ureteral dissection with resection of the cervicovesical fascia, cardinal and uterosacral ligaments were successful with ultrasonically activated instruments only. CONCLUSION: Our initial experience with laparoscopically assisted radical vaginal hysterectomy type II confirmed that the use of a minimally invasive ultrasonic technique is feasible. Further investigations into the indications of disease where laparoscopic surgery is appropriate in the management of early cervical carcinoma are required.

Short-term results from laparoscopic dissection of uterine vessels in women with symptomatic fibroids.

OBJECTIVE: To assess the outcome, tissue trauma, clinical improvement and the reduction in size of fibroid following laparoscopic dissection of uterine vessels (LDUV). SETTING: Department of Obstetrics and Gynaecology, Endoscopic Training Centre, Baby Friendly Hospital, Kladno, Czech Republic. DESIGN: An uncontrolled case series of 17 consecutive women who underwent LDUV using ultrasonically activated shears for the treatment of fibroids over two years. Ultrasound imaging was carried out before and three and six months following treatment. The tissue markers (C-reactive protein (CRP), Interleukin-6 (IL-6), Creatin kinase (CK) and white blood cell count) were studied preoperatively, on the first and third postoperative day. RESULTS: All patients underwent successful LDUV without intraoperative complications. Tissue markers results show that the LDUV performed using ultrasonically activated shears is associated with insignificant tissue damage. Time of surgery ranged from 30 to 50min (mean 39min). Mean blood loss was less than 30ml and mean hospital stay was 2.3 days. Three and six months after surgery, respectively, average reduction in uterine volume was 23.6 and 36.8% and average reduction in dominant fibroid was 28.6 and 56.8%. 94.1% of women had improvement in menorrhagia or dysmenorrhoea, and 91.6% had improvement in bulk-related symptoms or pelvic pain six months after treatment. CONCLUSION: Uterine volume and dominant fibroid were reduced and symptoms were improved by LDUV. The procedure of laparoscopic dissection of uterine vessels can be completed within 30-40min with only minimal blood loss and short hospital stay if performed by experienced laparoscopists.

[Minimally invasive surgical treatment of symptomatic myomas using laparoscopic dissection of uterine vessels: prospective clinical study (part I)]. / Minimálne invazivní operacní lécba symptomatických myomu pomocí LDUV (laparoskopická disekce delozních cév): klinická prospektivní studie (cást I).

OBJECTIVE: To assess the clinical outcome, indication and operative technique of laparoscopic dissection of uterine vessels (LDUV) using ultrasonic technique in the treatment of symptomatic fibroids. DESIGN: Prospective case observational clinical study (Part I). SETTING: Department of Obstetrics and Gynecology, Hospital Kladno. METHODS: We analysed clinical outcome of laparoscopic dissection of uterine vessels in 46 symptomatic women with fibroids in the period 2000-2002. The operative technique and indication to surgery were studied especially in part I. RESULTS: All patients underwent successful LDUV procedure without intraoperative complications. Time of surgery ranged from 15-50 minutes (mean 37.3 minutes) in cases of LDUV only. In cases of laparoscopic dissection of uterine vessels combined with myomectomy the mean of surgery was 63.1 minutes (range 35-120). Mean blood loss was less than 25 ml and mean hospital preoperative stay 2.1 days. Only two minor febrile preoperative complications was found (4.3%). CONCLUSION: The procedure of laparoscopic dissection of uterine vessels can be completed within 25-35 minutes with minimal blood loss, short hospital stay and acceptable number of complications.

Inflammatory response and tissue trauma in laparoscopic hysterectomy: comparison of electrosurgery and harmonic scalpel.

OBJECTIVE: Our aim was to quantify and compare clinical outcome and surgical inflammatory response and tissue trauma after laparoscopic hysterectomy for a benign disorder which was performed by electrosurgery or harmonic scalpel. METHODS: Sixty patients scheduled for laparoscopic hysterectomy were selected according to patient preference to undergo either electrosurgery or an ultrasonic operative technique. Blood samples for assay of markers of tissue trauma (C-reactive protein, interleukin-6, creatine kinase, white blood cell count) were taken preoperatively, on the first and third postoperative day. Three patients with intraoperative complications or incomplete records were excluded from tissue analysis. RESULTS: No differences were present in the demographic characteristics and clinical outcomes (blood loss, uterine weight, operating time and hospital stay) in 57 uncomplicated laparoscopic hysterectomies. Both electrosurgery (n = 36) and use of the harmonic scalpel (n = 21) resulted in statistically significant changes in the inflammatory and systemic immune response in comparison with preoperative values. No significant differences were observed in the studied inflammatory and tissue markers (C-reactive protein, interleukin-6, creatine kinase and white blood cells) between the compared groups. CONCLUSION: The harmonic scalpel and electrosurgery in laparoscopic hystsrectomy were equally traumatic in terms of surgical inflammatory response and tissue trauma.

Laparoscopic lymph node dissection using ultrasonically activated shears: comparison with electrosurgery.

PURPOSE: To assess and compare perioperative parameters in two groups of patients treated by different laparoscopic techniques of lymph node dissection (LND) for gynecologic cancer. PATIENTS AND METHODS: Between April 1996 and March 2001, 59 consecutive women with microinvasive cervical cancer (N = 5) or clinical stage I endometrial cancer (N = 54) underwent laparoscopic LND during a primary staging procedure using an electrosurgery (ELC) or ultrasonic (US) operative technique. The two groups were compared for perioperative outcomes. Differences between the two groups were determined by the Wilcoxon's rank-sum test. RESULTS: Laparoscopic LND and other staging procedures were completed successfully in 58 women (98.3%). There were no statistically significant differences between the groups with regard to perioperative outcomes (operation time, time for LND, blood loss, hospital stay, complications), but there was a significant difference (P = 0.0008) in the number of lymph nodes harvested: a mean of 13.7 in the ELC group and 17.5 in the US group. The pathologists found that the reading of histology slides was easier after US dissections because of the greater depth of thermal injury in the lymphatic tissue in ELC group. CONCLUSION: The US operative technique ensures efficient coagulation, cutting, dissection, and grasping for laparoscopic LND in patients with cervical and endometrial cancer.

Laparoscopic ultrasonic dissection of uterine vessels in women with benign uterine pathologies.

Uterine artery dissection is a new minimally invasive surgical technique used for the treatment of leiomyomas and adenomyomas. Three women underwent laparoscopically-assisted bilateral uterine dissection using ultrasonically activated shears. Surgery was uneventful, and patients were discharged on the second day after. Reduction in tumor volume measured by ultrasound was impressive (36%-68%), and the women felt their symptoms had improved. A larger series and longer follow-up are required to evaluate which patients will benefit from this technique. To our knowledge, this is the first report in the literature of origin uterine artery dissection in the area of the off-going part from the hypogastric artery using ultrasonically activated shears in symptomatic leiomyomas.

Comparison of two procedures for sentinel lymph node detection in patients with endometrial cancer: a pilot study.

OBJECTIVE: The purpose of this study was to assess the feasibility and contribution of two intraoperative procedures of lymphatic mapping and sentinel node detection using a blue dye in surgically-staged patients with early stage endometrial cancer. METHODS AND MATERIALS: In 25 cases of endometrial cancer, patent blue-V was injected into the subserosal myometrium (13 cases, SM group) or cervico-subserosal myometrium (12 cases, CSM group) during a surgical staging procedure. Laparoscopically-assisted vaginal hysterectomy and pelvic lymphadenectomy were completed successfully in 23 women out of 24 laparoscopically-staged patients (95.8%). One patient with FIGO stage IIa was indicated for a radical abdominal surgery. RESULTS: A deposition of the blue dye was found in at least one pelvic lymph node (LN) in eight out of 13 cases (61.5%) in the SM group compared with ten out of 12 cases (83.3%) in the CSM group (p = 0.378). The mean number of dye-colored LN (DCLN) was 1.15 (SM group) and 2.5 (CSM group), respectively (p = 0.05). The rate of DCLN/LN was 15/188 (SM group) versus 30/190. respectively (p = 0.03). An uptake of the blue bye was observed in a total of 45 out of 388 LN. CONCLUSION: An intraoperative combination of cervico-subserosal myometrium application of the blue dye allows successful detection (83.3%) of sentinel LN in patients with endometrial cancer. Comparing SM and CSM groups the statistical significant difference was found in the DCLN/LN rate and mean number of sentinel lymph nodes (p = 0.03, p = 0.05, respectively). Clinical validity of this surgical procedure must be assessed prospectively.

Laparoscopic staging of endometrial cancer using laparosonic instruments: comparison with electrosurgery.

OBJECTIVE: To compare perioperative parameters in two groups of women with different laparoscopic operative techniques in surgical staging of endometrial cancer (EC). STUDY DESIGN: Thirty randomly allocated and laparoscopically treated women with EC. Fifteen patients were operated by electrosurgery, 15 patients by laparosonic operative technique. Differences between the two groups were determined by the Wilcoxon rank-sum test. Probability (P) of less than 0.05 was considered significant. SETTING: Department of Gynecology and Obstetrics, Endoscopic Training Center, Baby Friendly Hospital, Kladno, Czech Republic. RESULTS: Laparoscopy was successfully completed in 29 patients. Laparoscopy-assisted surgical staging of EC was performed based on the tumor grade and the depth of myoinvasion. In both groups, in total 18 and 5 women underwent pelvic lymphadenectomy (PLN) and infra-aortic lymph node sampling (IALS), respectively. Three patients had metastases in pelvic lymph nodes. In the electrosurgical hemostasis and laparosonic group the mean total time required to finish the whole operative procedure were 132.1 and 138.3 min, respectively, with no statistically significant difference (P=0.96). There were no significant differences between the groups in any intraoperative or postoperative follow-up variables, except for the number of excised lymph nodes where the difference between electrosurgery and laparosonic group (12.7 versus 18) was statistically significant (P=0.05). In one patient with intraoperative venous bleeding the laparosonic hemostasis was ineffective (successful procedure rate 93.3%). One patient from the electrosurgery group was converted to laparotomy due to injury to the epigastric vessels. This complication had no connection with the surgical techniques studied. CONCLUSION: It is concluded that both operative technique variants in laparoscopy-assisted surgical staging appear to be feasible and effective for patients with EC.

[Laparoscopic-assisted myomectomy--surgical technique and indications]. / Laparoskopicky asistovaná myomektomie--operacní technika a indikace.

OBJECTIVE: To analyze perioperative outcomes of laparoscopically assisted myomectomy. DESIGN: Pilot study. SETTING: Department of Obstetrics and Gynaecology, Endoscopic Training Centre, Hospital Kladno, Czech Republic. MATERIAL AND METHODS: Eight consecutive women with fibromyoma were treated by laparoscopic assisted myomectomy. Laparoscopic surgery was performed based on size of fibromyoma over 6 cm. RESULTS: The application of the operative technique of laparoscopically assisted myomectomy was effective in all out exception. In the studied group the mean operative time and the mean of weight of the specimen were 76 min (range 50-90) and 151.7 g (range 45-220), respectively. In one patient the relaparoscopy for bleeding was necessary. CONCLUSION: Laparoscopic assisted surgery is feasible in women with fibromyoma and may also be considered for myomectomy.

Laparoscopic hysterectomy in obese women: a clinical prospective study.

OBJECTIVE: To compare perioperative and postoperative outcomes of laparoscopic hysterectomy (LH) in surgical management of gynecological conditions in two groups of different weight. METHODS: A prospective comparative clinical study of 271 LH performed for disease of female pelvic organs in a group of 54 obese patients (over 30 body mass index (BMI)) and in a group of 217 non-obese patients (less than 30 BMI). The following criteria were assessed: patient characteristics, indications for surgery, previous surgery, presence of adhesions, duration of procedure, blood loss, weight of specimen, hospital stay and complications. Statistical analysis was performed using the unpaired t-test and non-parametric Chi-square test when appropriate, with a significance level of P=0.05. RESULTS: Three non-obese patients were converted to laparotomy due to operative complications. Laparoscopy in the remaining 268 patients (98.89%) was completed successfully. There was no significant difference in estimated blood loss, presence and degree of adhesions, weight of specimen, length of hospital stay and postoperative complications between women with high BMI and those with low BMI. The rate of major operative complications (5.55% versus 3.22%) was higher in the obese group. The duration of the operation was longer in obese women. However, the significance of the difference was borderline (P=0.06).

Laparoscopically-assisted intraoperative lymphatic mapping in endometrial cancer: preliminary results.

OBJECTIVE: To analyse the results of a pilot study and determine the contribution of laparoscopically-assisted lymphatic mapping in patients with endometrial cancer. METHODS AND MATERIALS: In eight cases of early endometrial cancer, patent blue-V was injected laparoscopically into the uterine wall during a surgical staging procedure. RESULTS: A deposition of the blue dye was found in at least one pelvic lymph node in five of eight cases. Blue-colored nodes were observed in a total of 11 lymph nodes. Locations of these nodes included obturator, internal and common iliac sites. Only one blue colored node was positive for disease. An average of 15 lymph nodes were removed in the study group (range, 12-22). Uterine lymphatic vessels with bilateral drainage to the broad and infundibulopelvic ligaments were seen in all cases within 30-60 seconds. CONCLUSION: Our initial experience with laparoscopically-assisted lymphatic mapping confirmed that the use of a minimally invasive technique is feasible. Lymphatic channels in the pelvic areas were seen in every patient. A deposition of blue dye in laparoscopically identifiable lymph nodes was seen only in 62.5% of patients. However, we believe that the lymphatic mapping of the uterine corpus can improve the accuracy of surgical staging in patients with endometrial cancer.

Does hysterectomy without salpingo-oophorectomy influence the reoperation rate for adnexal pathology? A retrospective study.

OBJECTIVE: The aim of this study was to assess if the abdominal, vaginal and laparoscopic approach to hysterectomy can affect the incidence of ovarian or adnexal pathology after hysterectomy without salpingo-oophorectomy. METHODS: In this study 17 cases out of 617 hysterectomies were found to have development of adnexal pathology; reoperation rate was 2.75%. RESULTS: The reoperation rate was significantly different (p < 0.006) in the observed approaches to hysterectomy (TAH 5.67%, VH 0.69%, LH 3.18%). The greatest difference was found between the abdominal and vaginal groups. CONCLUSION: Our study results have sufficiently shown that the relationship of a number of factors (age, primary histologic findings, smaller peritoneal trauma) had an important impact on a significant difference in reoperation rate between vaginal, laparoscopic and namely abdominal hysterectomies in female patients with preserved adnexa.

Hemostasis using tissue glue in laparoscopy: discussion and review.

OBJECTIVES: To discuss the usefulness of tissue glue and TachoComb (TC), a new hemostyptic agent which combines the advantages of two reliable hemostyptic products-collagen fleece and fibrin glue in local hemostasis during laparoscopy. SETTING: Department of Gynecology and Obstetrics, Endoscopic Training Centre, Hospital Kladno. DESIGN: Review. METHODS: Analysis of literary and clinical data. RESULTS: In recent years, collagen fibers, gelatin sponges, oxidized cellulose and fibrin glue has been developed, which are now widely used in postoperative hemostasis in laparoscopy. An efficient use of these preparations shortens the duration of intervention procedures and reduces patient strain. CONCLUSIONS: Clinical studies demonstrate that hemorrhage from damage tissue important pelvic structures can be successfully arrested and controlled using the laparoscope to apply tissue glue. At Czech study, sixteen patients have been effective treated with collagen-fibrin agent during laparoscopic operations. The elimination of hemorrhages after primary laparoscopic electrosurgery and the effectiveness of this drug have been successfully tested.