Transvaginal liver surgery using a tethered magnet and a laparoscopic rein.

INTRODUCTION: A novel technique was used to remove a large liver cyst via culdolaparoscopy. CASE DESCRIPTION: We used laparoscopic instruments, a gastroscope, a laparoscopic rein, and magnets. The magnets consist of an external magnet and a specially modified tethered neodymium internal magnet, safe for use in transvaginal endoscopic surgery. DISCUSSION: These technologies offer some advantages when they are used together: magnets and the rein to aid in exposure, traction-retraction, and triangulation. Previous reports have been published on the removal of benign liver lesions transvaginally, but none to date has involved the use of magnets. This article reports on the role of magnets and reins in an incision reduction approach to the removal of a liver cyst.

Lymphocele prevention after pelvic laparoscopic lymphadenectomy by a collagen patch coated with human coagulation factors: a matched case-control study.

OBJECTIVE: Lymphoceles are among the most common postoperative complications of pelvic lymphadenectomy (PL), with a reported incidence of 1% to 50%. Symptoms are pelvic pain, leg edema, gastrointestinal obstruction, obstructive uropathy, and deep vein thrombosis, and severe complications such as sepsis and lymphatic fistula formation. After laparoscopic PL, we tested the prevention of lymphoceles using collagen patch coated with the human coagulation factors (TachoSil, Nycomed International Management GmbH, Zurich, Switzerland) on 55 patients with endometrial cancer stages IB to II who had undergone laparoscopy. MATERIALS AND METHODS: The authors divided the patients into 2 laparoscopy groups: PL plus TachoSil (group 1: 26 patients) and PL without TachoSil in a control group (group 2: 29 patients), as historical cohort of patients who underwent PL between 2010 and 2012. We collected surgical parameters, and the patients underwent ultrasound examination on postoperative days 7, 14, and 28. The main outcome measures were the development of symptomatic or asymptomatic lymphoceles, the need for further surgical intervention, as adverse effect of surgery, and the drainage volume and duration. RESULTS: The same number of lymph nodes in both groups was removed; group 1 showed a lower drainage volume. Lymphoceles developed in 5 patients in group 1 and in 15 patients in group 2; of these, only 2 patients were symptomatic in group 1 and 5 patients were symptomatic in group 2, without statistical difference and no percutaneous drainage request. CONCLUSIONS: In this preliminary investigation, the intraoperative laparoscopy application of TachoSil seems to reduce the rate of postoperative lymphoceles after PL, providing a useful additional treatment option for reducing drainage volume and preventing lymphocele development after PL.

Bladeless direct optical trocar insertion in laparoscopic procedures on the obese patient.

BACKGROUND: Recently, we have shown advantages of a direct optical entry (DOE) using a bladeless trocar in comparison with the open Hasson technique (OHT) in older reproductive-age women with previous operations, as well as in comparison with Veress needle entry in reproductive-age and postmenopausal women. OBJECTIVES: A prospective multicenter randomized study to determine whether the DOE is feasible for establishing safe and rapid entry into the abdomen in comparison with those of the OHT in reproductive-age obese women. METHODS: Two types of surgical techniques were blindly applied in 224 obese reproductive-age women with benign neoplastic diseases of ovary and uterus. Namely, laparoscopic entry into the abdomen in 108 patients was performed by DOE and in 116 women by OHT. Following parameters (entry time in seconds needed to establish the intra-abdominal vision after pneumoperitoneum, blood loss, occurrence of vascular and/or bowel injuries) were compared during surgery as main outcomes. RESULTS: Main baseline characteristics of patients, including age (36.1 ± 4.5 vs 35.7 ± 5.8), body mass index (34.9 ± 5.1 vs 35.1 ± 4.9 kg/m(2)), and parity (2.1 ± 0.4 vs 1.9 ± 0.9), were not significantly different between the DOE and OHT groups (P > .05). While intraoperative parameters such as the entry time (71.9 ± 3.7 vs 215.1 ± 6.2 seconds) and blood loss value (9.7 ± 6.1 vs 12.2 ± 2.9 mL) were significantly reduced in the DOE group in comparison with those of OHT group (respectively, P < .0001 and < .01), there were also trends to slight decrease of the occurrence of the minor injuries, manifested as omental small vessels rupture (0 of 108 vs 4 of 116) and punctures and pinches of jejunal serosa (0 of 108 vs 3 of 116) in patients of the DOE group in comparison with those of OHT group (respectively, P = .0515 and = .0925). CONCLUSIONS: DOE reduced entry time and blood loss with trends to slightly decrease of the occurrence of the minor vascular and bowel injuries, thus enabling a possible alternative to OHT in obese women; however, further larger trials need to confirm the possible additional benefits of a DOE.

Laparoscopic myomectomy focusing on the myoma pseudocapsule: technical and outcome reports.

BACKGROUND: Our aim was to assess surgical complaints and reproductive outcomes of laparoscopic intracapsular myomectomies by a prospective observational study run in University affiliated hospitals. METHODS: Between 2005 and 2010, 235 women underwent subserous and intramural laparoscopic myomectomy of fibroids (4-10 cm in diameter) for indications of pelvic pain, menstrual disorders, a large growing myoma or infertility. The main outcome measures were post-surgical parameters, including complications, the need for subsequent surgery or symptomatic relief, resumption of normal life and reproductive outcome. RESULTS: Pelvic pain occurred in 27%, menorrhagia or metorrhagia in 21%, a large growing myoma in 10% and infertility in 42% of women. Single fibroids occurred in 51.9% of patients while 48.1% had multiple myomas. Of all patients, 58.2% had subserosal and 41.8% had intramural myomas. No laparoscopies were converted to laparotomy. In 3 years, 1.2% of patients had a second laparoscopic myomectomy for recurrent fibroids. The mean total operative laparoscopic time was 84 min (range 25-126 min), with mean blood loss of 118 ± 27.9 ml. By 48 h after surgery, 86.3% were discharged with no major post-operative complications. No late complications, such as bleeding, urinary tract infections or bowel lesions, occurred. Of the women who underwent myomectomy for infertility, 74% finally conceived. At term, 32.9% of patients underwent Caesarean section, 24.8% delivered by vacuum extractor and 42.2% had spontaneous deliveries. No case of uterine rupture occurred. CONCLUSIONS: Intracapsular subserous and intramural myomectomy saving the fibroid pseudocapsule showed few early and no late surgical complications, enhanced healing by preserving myometrial integrity and allowed a good fertility rate and delivery outcome. In young patients suffering fibroids, laparoscopic intracapsular myomectomy is a potential recommended surgical treatment.

The management of fibroids based on immunohistochemical studies of their pseudocapsules.

BACKGROUND: We examined the presence of collagen IV and laminin in the pseudocapsule of uterine myomata to clarify different ultra-structural characteristics and their possible role in the management of this condition. METHODS: Twenty non-pregnant patients underwent laparoscopic intracapsular myomectomies. Samples of the removed fibroids pseudocapsules were analyzed by immunochemical staining for collagen IV, immunohistochemical location of the vascular membrane-bound laminin and quantitative analysis of their images. RESULTS: In the blood vessels of the pseudocapsules, a reduction in laminin and increase in collagen IV with increasing diameter of fibroids was noted. These proteins are related to loss of the basal membrane and to ageing of the tissue. The increase of collagen IV is linked to the increase of amorphous substance, including glycosaminoglycans and glycoproteins. CONCLUSION: Based on immunohistochemical findings, the authors propose to remove fibroids in women seeking pregnancy whilst respecting the pseudocapsule by neurofibre sparing in the incision site. This is essential for optimal muscular healing and myometrial function in future pregnancies, and also when fibroids remain under 6 cm diameter, especially in young women wishing pregnancies. Fibroid removal should be performed before the myoma reaches a size causing compression of the surrounding tissues, which results in the loss of regenerative potential.

Laparoscopy entry in patients with previous abdominal and pelvic surgery.

BACKGROUND: The background of this investigation is based on a common surgical problem: The access in laparoscopic surgery is more difficult in women with previous abdominopelvic surgery, since adhesions and viscera could be close to the point of trocar insertion. PURPOSE: The authors analyzed the safety and the efficacy of a modified direct optical entry (DOE) method versus the Hasson's method by open laparoscopy (OL) in women with previous abdominopelvic surgery in a preliminary prospective case-control study. MATERIALS AND METHODS: A total of 168 women underwent laparoscopic surgery in university-affiliated hospitals: 86 were assigned to abdominal DOE (group A) and 82 to OL (group B). The main outcome measures were statistically compared: time required for entry into abdomen, blood loss, and occurrence of vascular and/or bowel injury. All patients had an intraperitoneal view of the primary port site during surgical procedure. RESULTS: Statistical differences, in favor of the DOE group (P < .01), were found in duration of entry and blood loss. The vascular and bowel injuries in OL versus DOE were not statistically different. CONCLUSIONS: Obtaining access to the peritoneal cavity in laparoscopic surgery is more difficult in patients with previous abdominopelvic surgery, since it can become a difficult, time-consuming, and occasionally hazardous procedure. The study results suggest that DOE is advantageous when compared with OL in terms of saving time enabling a safe and expeditious visually guided entry for laparoscopy.

Adhesion formation after intracapsular myomectomy with or without adhesion barrier.

OBJECTIVE: To show the prevention of adhesion formation by placing an absorbable adhesion barrier after intracapsular myomectomy. DESIGN: Prospective blinded observational study. SETTING: University-affiliated Hospitals. PATIENT(S): Patients ≥ 18 years old with single or multiple uterine fibroids removed by laparoscopic or abdominal intracapsular myomectomy. INTERVENTION(S): A total of 694 women undergoing laparoscopic or abdominal myomectomy were randomized for placement of oxidized regenerated cellulose absorbable adhesion barrier to the uterine incision or for control subjects without barriers. The presence of adhesions was assessed in 546 patients who underwent subsequent surgery. MAIN OUTCOME MEASURE(S): The primary and secondary outcomes of the analysis were the presence and severity of adhesions for four groups: laparotomy with barrier, laparotomy without barrier, laparoscopy with barrier, and laparoscopy without barrier. RESULT(S): There was a higher rate of adhesions in laparotomy without barrier (28.1%) compared with laparoscopy with no barrier (22.6%), followed by laparotomy with barrier (22%) and laparoscopy with barrier (15.9%). Additionally, the type of adhesions were different, filmy and organized were predominant with an adhesion barrier, and cohesive adhesions were more common without an adhesion barrier. CONCLUSION(S): Oxidized regenerated cellulose reduces postsurgical adhesions. Cohesive adhesions reduction was noted in laparoscopy.

Distribution of substance P (SP) and vasoactive intestinal peptide (VIP) in pseudocapsules of uterine fibroids.

The authors examined the presence of Substance P (SP) and Vasoactive Intestinal Polypeptide (VIP) and their related fibers in the pseudocapsule of uterine fibroids (PUF) and in normal myometrium (NM) during myomectomies in 57 non-pregnant women. 4 samples were removed from the normal myometrium (NM) and from PUF. The samples were sent for histological and immune-fluorescent investigations. SP and VIP values were found non-significantly higher in PUF than in NM: SP values were 10.2±0.1 conventional units (C.U.) in PUF at the fundus of the uterus (FU) vs. 8.1±0.6C.U. of NM in the FU (p>0.05), and SP values were 25.1±0.9C.U. in PUF in the uterine body (UB) compared to. 23.2±1.4C.U. of NM in the myometrium of the UB (p>0.05). VIP values were 11.5±0.9C.U. in the PUF in FU compared to 9.8±1.4C.U. of NM in the FU (p>0.05), and VIP values were 33.9±3.9C.U. in the PUF in the UB vs. 32.6±4.8C.U. of the NM in the UB (p>0.05). These findings show that SP and VIP neurofibers are present in the fibroid pseudocapsule, similar to the values in the normal myometrium of a non-pregnant uterus. An intracapsular myoma excision which respects the pseudocapsule permits a physiological healing process of the uterine scar, due to a neurotransmitter sparing at the hysterotomic site. In women planning pregnancy, the myomectomy should be preferably performed respecting the pseudocapsule in order to preserve the neurotransmission.

Laparoscopic intracapsular myomectomy: comparison of single versus multiple fibroids removal. An institutional experience.

OBJECTIVE: The aim of this study was to compare single versus multiple laparoscopic myomectomy with an intracapsular method. STUDY DESIGN: A total of 335 laparoscopic intracapsular myomectomies were compared. They were subdivided into two groups. Group I included 195 patients with myoma; group II, 140 patients with multiple myomas, 4-9 cm in diameter. Laparoscopic procedures were compared with respect to intraoperative complications, postoperative compliance, and general surgical feedback. Results were analyzed using SAS software (version 8), considering a P-value of <0.05 as significant. RESULTS: No differences (P>0.05) between groups were observed with respect to the following: intraoperative blood loss (98 ± 4.7 mL of group I versus 106 ± 6.8 mL of group II), catheter inside pelvis for postsurgical drainage (40% versus 36.4% women), analgesic administration for the first 24 hours (41.5% versus 40% patients), postoperative fever after 24 hours (11.2% versus 9.2% women), postoperative therapeutic antibiotics administration (8.2% versus 6.4% patients), and hospitalization and postoperative ultrasound (US) intramyometrial hematoma detection (6.6% versus 5.7% of group II). The only surgical statistical difference (P<0.05) was in the mean total laparoscopic time (60 ± 7.2 minutes for group I versus 97 ± 8.9 minutes for group II). CONCLUSIONS: Intracapsular laparoscopic myomectomies, performed in the same session on a single or on multiple fibroids, seem to preserve myometrial integrity and allow the restoration of uterine scar, with few early and late surgical complications.

Laparoscopical management of cornual pregnancies: a report of three cases.

OBJECTIVE: Cornual pregnancy refers to the implantation and development of a gestation in one of the upper and lateral portions of the uterus; authors report their experience in laparoscopic therapeutic procedures on three singleton cornual pregnancies. STUDY DESIGN: Three healthy women were admitted in General Hospitals with suspect of cornual pregnancies by clinical examination, increasing of beta-hCG value and transvaginal ultrasonography. One of them had a haemoperitoneum. Surgeons performed all operative laparoscopies, by incision and enucleating of ectopic cornual mass, coagulating of its surrounding vessels and suturing of the uterine incision site. RESULTS: Patients were successfully treated only by laparoscopy, post-operative recovery period was normal in all women, with no further therapeutically intervention in the follow-up course. The aftermath was uneventful at the follow-up of 2 years. CONCLUSION: In cornual pregnancies, the minimally invasive surgical treatment by salpingotomy or resection of the cornual region of the uterus and the suturing of the incision site, should be the option in women interested in future fertility.