Journal of Laparoendoscopic & Advanced Surgical Techniques

Surgical Technique Based on Space Anatomy for Laparoscopic Radical Trachelectomy with Uterine Artery Preservation

Background: To introduce the surgical procedure based on special space anatomy that can safely and efficiently complete the dissociation of the ureter and uterine artery during laparoscopic radical trachelectomy with uterine artery preservation. Methods: We introduce the key technique elements of this surgical procedure using a patient we treated as an example. A 27-year-old patient was diagnosed as well-differentiated cervical adenocarcinoma, stage IB1, and had a strong desire for future fertility. Laparoscopic radical trachelectomy with uterine artery preservation was performed in this patient by using this new surgical technique based on space anatomy. Results: The ureteral space that needs to be dealt with during laparoscopic radical trachelectomy is actually a potential avascular space located medial to the ureter between the anterior leaf (from the axillary space to the fourth space of Yabuki) and posterior leaf (between the paravesical space and paravaginal space) of the vesicouterine ligament. Exposure of the axillary space can help to separate the ureter from the lower uterine segment and uterine artery (uterine side), which is necessary for radical trachelectomy with uterine artery preserved. Multiple “shafts” called potential avascular space can be drilled on the anterior leaf of vesicouterine ligament, and the connective tissue and blood vessels between the “shafts” were cutoff with ultrasonic scalpel. After the paravesical space and paravaginal space were developed, the posterior leaf was isolated and congealed completely by Ligasure. Conclusions: In brief, this new surgical procedure consists of four spaces that can safely and efficiently perform complete excision of the vesicouterine ligament, reduce blood loss, avoid ureteral injury, and shorten the operation time.

Results of Ovarian Sparing Surgery in Pediatric Patients: Is There a Place for Laparoscopy?

Background: Laparoscopy is widely accepted for the surgical treatment of benign ovarian lesions in adult women, with results similar to an open approach when spillage is avoided by different means such as endobag retrieval. This approach is controversial in children. Materials and Methods: Retrospective study (2009–2018) of all pediatric ovarian tumors with histological confirmation treated in a tertiary center. Data regarding preoperative selection criteria, surgical technique, and follow-up were registered. Laparoscopy was used only in tumors without malignant features and whose size allowed retrieving them through a small incision without morcellating. Emphasis was set in ovarian sparing surgery (OSS), comparing the results of open (OP) and laparoscopic (LPC) approach. Results: During the study period, 48 suspicious lesions in 45 patients were operated. Thirty cases (32 tumors) showed benign features (10 cystadenomas, 14 mature teratomas, 6 nontumor lesions); treatment consisted in oophorectomy in 13 (OP 6, LPC 7) and OSS in 17 (OP 5, LPC 12). There was one conversion in the LPC group. Mean follow-up was 3.44 years (range 0.03–8.84), based on annual ultrasound (US) and tumor markers during at least 5 years, recommending a lifetime follow-up by a gynecologist. There was only one relapse in a laparoscopically enucleated cystadenoma, and 2 patients developed contralateral metacronous teratomas. No procedure-related complications happened. Conclusions: Our series, although small and with a limited follow-up, suggest that laparoscopy could be an option of treatment in a subset of highly selected patients, although laparotomy remains the gold standard approach if malignancy is suspected.

Laparoendoscopic Ovarian-Sparing Surgery of Adnexal Tumors in Children and Adolescents by General Gynecologists: A 10-Year, Retrospective Cohort Study

Background: In pediatric and adolescent gynecology, ovarian-sparing surgery (OSS) is an approach for preserving the ovaries affected by tumors and torsion during surgical treatment. Materials and Methods: We analyzed participants from a tertiary Gynecology and Obstetrics University Hospital. Participants were patients <19 years of age with adnexal tumors managed surgically with removal of pathologically confirmed ovarian tissue in the period from 2008 to 2017. Results: The average age of 38 patients who underwent surgery for adnexal tumors and were included in the study was 16.78 ± 2.15 years, from 12 to 19 years, with significantly younger patients in the salpingo-oophorectomy/oophorectomy and laparotomy group ( P  = .036 and P  = .001). The laparoscopic approach was performed in 28 (73.68%) patients and laparotomy in 10 (26.31%) patients ( P  < .0001). Cystectomy was performed in 29 (76.31%), oophorectomy in 1 (2.63%), and salpingo-oophorectomy in 8 (21.05%) patients. A significantly higher number of patients underwent OSS with laparoscopy in scheduled surgical procedure and emergency surgery groups ( P  = .021 and P  = .028). Benign ovarian tumors were found in 31 (81.57%), borderline in 3 (7.89%), and malignant in 4 (10.52%) patients. Conclusion: Our study has shown a high trend in OSS using the endoscopic approach in management of adnexal tumors despite the fact that the management was done by general gynecologists.

Treating Benign Ovarian Lesions in the Pediatric Population: A Single Institution’s Retrospective Investigation of Laparoscopy Versus Open Repair

Background: Benign ovarian lesions in the pediatric population have variable risk of recurrence or development of metachronous lesions, leading to variations in operative approach. Our study compares outcomes with differing surgical approaches to better elucidate risk of recurrent or metachronous lesions, time to development of these lesions, and hospital length of stay to determine if one operative approach has superior outcomes. Methods: We retrospectively examined data from Indiana University Health facilities from 2002 to 2020. Patients ≤18 years old who underwent surgical management of a benign ovarian lesion were included. Patients were categorized as undergoing oophorectomy versus ovarian sparing surgery (OSS), with open and laparoscopic approaches. Significance was defined as P < .05. Results: We identified 127 patients who underwent an open ( n = 65) versus laparoscopic ( n = 55) surgical approach. Patients undergoing open surgery had a greater mean size of lesion ( P = .05) and longer length of stay ( P < .01). Complication rates ( P = .1), rates of developing a metachronous or recurrent lesion postoperatively ( P = .47), and time to formation of additional lesions were similar between groups ( P = .25). The incidence of identifying an additional lesion after surgery was 14.2% ( n = 18) in the mean time of 29.5 ± 31.6 months [SEM 7.5]. Risk of developing a metachronous lesion was similar regardless of the operative approach. Surgery for recurrent ovarian lesions was rare and occurred in only 1 case. Conclusions: Laparoscopic surgery was performed for smaller lesions and was associated with a shorter length of hospital stay. Laparoscopic and OSS was found to have no increased risk of developing metachronous lesions nor increased reoperative risk compared with traditional open and oophorectomy techniques.

Laparoscopy for Ovary-Sparing Tumorectomy in Children with Ovarian Tumors: A Clinical Retrospective Analysis

Objective: The aim of this study is to analyze the characteristics of pediatric ovarian tumors (OTs) and evaluate treatment strategies for ovary-sparing tumorectomy (OST). Materials and Methods: Medical records of children from October 2011 to December 2021 were reviewed. Data regarding clinical characteristics, pathological type, and management of OST were analyzed. Results: In total, 61 patients with OTs were screened. The median age was 14.8 ± 3.0 years. The median length and volume of borderline and malignant OTs were larger than those of benign OTs ( P  < .001 and P  = .05, respectively). There was a significant difference in the median OT volume between torsion and nontorsion OTs ( P  = .04). The overall OST rate was 91.8% (67/73). A total of 53.4% (39/73) lesions were treated with laparoscopic OST. The OT volume was smaller in patients who underwent laparoscopy than in those who underwent laparotomy ( P  = .04). The probability of intraoperative tumor rupture or spillage was higher during laparoscopy than during laparotomy ( P  = .02). No significant differences were observed in OT recurrence. Seven patients had borderline and malignant tumors, 3 of whom had stage IA tumors and underwent OST. None of the patients experienced relapse. Conclusions: OT size is a useful reference factor for differential diagnosis and choosing laparoscopic surgery. Intraoperative tumor rupture and spillage of benign tumors during laparoscopy and laparotomy did not seem to be associated with recurrence, and laparoscopic OST was considered safe. Further prospective studies are required to confirm these conclusions.

Laparoscopic Posterior Pelvic Exenteration (Complete and Supralevator) for Locally Advanced Adenocarcinoma of the Rectum in Females: Surgical Technique and Short-Term Outcomes

Background: Laparoscopic posterior exenteration (total and supralevator) is a complex and rarely done procedure. In this study we describe the surgical technique and short-term perioperative outcomes in 7 female patients of locally advanced carcinoma rectum operated with laparoscopic pelvic exenteration. Materials and Methods: We report 7 cases of carcinoma rectum involving either posterior wall of the uterus or vagina, which were operated with a laparoscopic procedure. All perioperative and intraoperative data were collected retrospectively from prospectively maintained electronic data. Results: Nine female patients with the diagnosis of nonmetastatic locally advanced lower rectal adenocarcinoma were selected. In MRI 4 patients had uterus-cervix involvement and 3 patients had a posterior vaginal wall and anal sphincter involvement. Four patients were operated with laparoscopic supralevator posterior exenteration and 3 patients were operated with laparoscopic complete posterior exenteration. Three patients underwent vaginal reconstruction, which was done with bilateral V-Y plasty. All 7 patients received neoadjuvant chemoradiotherapy (NACTRT), 3 patients also received additional chemotherapy (CAPOX regimen) due to poor response to NACTRT. Mean body mass index (BMI) was 23.85 (range 19–27.20). Mean duration for complete posterior exenteration was 9.63 hours (range 7–12 hours). Mean duration for supralevator posterior exenteration was 6.81 hours (range 6.25–7.5 hours). The mean postoperative stay was 10.71 days (range 7–16 days). Mean blood loss was 700 mL (range 200–1800 mL). On postoperative histopathology, all margins were free of tumor in all cases. Conclusion: Laparoscopic approach for locally advanced carcinoma rectum in female patients is feasible with less morbidity and safe short-term oncological outcomes. Careful selection of patients based on MRI is a must before undertaking the minimally invasive surgery approach. Long-term outcomes are still unknown and will require long-term follow-up.