Surgical Endoscopy

Lymph node evaluation for endometrial hyperplasia: a nationwide analysis of minimally invasive hysterectomy in the ambulatory setting

Abstract Background Given the possibility of occult endometrial cancer where nodal status confers important prognostic and therapeutic data, role of lymph node evaluation at hysterectomy for endometrial hyperplasia is currently under active investigation. The objective of the current study was to examine the characteristics related to lymph node evaluation at the time of minimally invasive hysterectomy when performed for endometrial hyperplasia in an ambulatory surgery setting. Methods The Healthcare Cost and Utilization Project's Nationwide Ambulatory Surgery Sample was retrospectively queried to examine 49,698 patients with endometrial hyperplasia who underwent minimally invasive hysterectomy from 1/2016 to 12/2019. A multivariable binary logistic regression model was fitted to assess the characteristics related to lymph node evaluation at hysterectomy and a classification tree model with recursive partitioning analysis was constructed to examine the utilization pattern of lymph node evaluation. Results Lymph node evaluation was performed in 2847 (5.7%) patients. In a multivariable analysis, (i) patient factors with older age, obesity, high census-level household income, and large fringe metropolitan, (ii) surgical factors with total laparoscopic hysterectomy and recent year surgery, (iii) hospital parameters with large bed capacity, urban setting, and Western U.S. region, and (iv) histology factor with presence of atypia were independently associated with increased utilization of lymph node evaluation at hysterectomy (all, P  < 0.05). Among those independent factors, presence of atypia exhibited the largest association for lymph node evaluation (adjusted odds ratio 3.75, 95% confidence interval 3.39–4.16). There were 20 unique patterns of lymph node evaluation based on histology, hysterectomy type, patient age, year of surgery, and hospital bed capacity, ranging from 0 to 20.3% (absolute rate difference, 20.3%). Conclusion Lymph node evaluation at the time of minimally invasive hysterectomy for endometrial hyperplasia in the ambulatory surgery setting appears to be evolving with large variability based on histology type, hysterectomy modality, patient factors, and hospital parameters, warranting a consideration of developing clinical practice guidelines.

A direct endoscopic approach for left-sided infrarenal para-aortic lymphadenectomy immediately after hysterectomy for endometrial cancer treatment: left dome formation (LDF)

Endoscopic surgery for infrarenal para-aortic lymphadenectomy has been widely accepted. Two major approaches, "transperitoneal" and "extraperitoneal", are generally used; however, they have several disadvantages. A "transperitoneal" approach to the left para-aortic region is usually indirect, often performed after wide extension of the right para-aortic region. An "extraperitoneal" approach is unsuitable when a peritoneal tear exists after a prior surgical procedure such as hysterectomy. Here, we propose a modified transperitoneal technique, "Left dome formation (LDF)," which directly provides a surgical field for left infrarenal para-aortic lymphadenectomy even after hysterectomy. The LDF procedure comprised three processes: (1) setting, (2) dissection of inframesenteric lymph nodes (step 1), and (3) dissection of infrarenal lymph nodes (step 2). two trocars were added 4 cm bilateral to the low-mid abdominal trocar that was used in prior hysterectomy. Step 1: The posterior layer of the renal fascia along with the left ureter and left ovarian vessel were separated from the left common iliac artery and iliopsoas. Left inframesentric nodes were removed from the surgical field. Step 2: The left ureter was isolated from the posterior renal fascia, and the dome was expanded cranially to the left renal vein, with the ovarian vein always visualizable at the dome ceiling. Left infrarenal nodes were removed. We applied LDF to ten endometrial cancer patients, recommended for additional dissection of para-aortic nodes based on intraoperative evaluation using the laparoscopically removed uterus. The operative time and number of removed lymph nodes in Step 1 and Step 2 were 28.8 (20-49) min and 5.3 (2-10) and 54.6 (52-70) min and 6.5 (1-11), respectively. Blood loss was below 50 ml. No serious organ injury occurred during procedures. Since the left ureter is always observable, LDF procedure facilitates effective surgery to overcome the anatomical complexity of the left para-aortic region and is potentially useful for sentinel node sampling.

Self-expanding metallic stent insertion for malignant bowel obstruction secondary to gynecologic malignancies: a retrospective analysis

Initial experience with the Carina™ platform in robotic-assisted hysterectomy for gynecological malignant disease

This retrospective study was performed to evaluate the efficiency and safety of a new modular robotic system, the Carina™ Platform (Ronovo Surgical, Shanghai, China), in gynecological surgery. All patients underwent robotic hysterectomies (RH) using the Carina performed by a single gynecologist experienced in laparoscopic and robotic surgery from November to December 2023. Patients were evaluated for estimated blood loss (EBL), intraoperative and postoperative complications, length of hospital stay, conversion rate, as well as console and docking times. Two separate populations were involved: 10 cervical cancer patients (group 1) and six endometrial cancer patients (group 2). There were no conversions to laparotomies or laparoscopies. The mean docking time was 5.75 ± 2.38 min. The mean console time and mean operative time were 154.60 ± 26.01 min and 211.90 ± 53.65 min in group 1, respectively. The mean console time and mean operative time were 98.67 ± 26.71 min and 153.33 ± 22.77 min in group 2, respectively. The median estimated blood loss for group 1 and group 2 were 30 ml (20, 50) and 20 ml (7.5, 20), respectively. No intraoperative or postoperative complications related to the device were recorded. Our experience allows us to state that the modular Carina Platform is safe and efficient in complex gynecologic surgery. researchregistry10353  https://www.researchregistry.com/browse-the-registry#home/registrationdetails/665c1a398a97c302739cce06/.

Combined robotic surgery for concomitant treatment of endometrial cancer and obesity

Endometrial Cancer (EC) is strongly linked to obesity. Bariatric surgery is recognized as a long-term solution for weight loss in severely obese patients. This pilot study investigates the feasibility, intraoperative and 30-day morbidity outcomes of integrating gynecological surgical staging and bariatric robotic surgery in class II and III obese patients affected by early EC or Endometrial Intraepithelial Neoplasia (EIN). Patients aged over 18 years old with early EC or EIN and class II and III obesity (Body mass index (BMI) ≥ 35 kg/m Of the 13 patients who met the inclusion criteria, 5 (38.46%) opted for combined surgery. The groups showed a significant difference in preoperative BMI (49.68 kg/m Integrating robotic EC staging with SG in obese women with early EC increased the operative time without increasing intraoperative risks, early and 30 days post-surgery complication and offering a promising approach to simultaneously treating both conditions.

Sentinel lymph node biopsy with carbon dye in endometrial cancer: a single center, prospective cohort study

Abstract Background Many agents have been used for the detection of sentinel lymph nodes in endometrial cancer. Carbon dye, which has a strong staining ability and high contrast due to its dark black color, identifies the lymph nodes efficiently. Our aim was to evaluate the safety and efficacy of carbon dye for the detection of sentinel lymph nodes in endometrial cancer. Methods We conducted a single-center, prospective, cohort study in 89 patients with early-stage endometrial cancer between September 2021 and August 2022. The procedure was performed under laparoscopy. Results The sensitivity and negative predictive value of the sentinel lymph node biopsy (SLNB) with carbon dye injection were 83.3% and 98.8%, respectively. Mapping identified at least one sentinel lymph node in 84 patients (94.4%) on one pelvic side and at least one sentinel lymph node in 73 patients (82.0%) on each pelvic side out of 89 patients. In addition, no carbon dye-associated allergic reaction was detected. Conclusion Carbon dye is a non-allergenic, inexpensive, and effective agent for SLNB with a satisfying sensitivity and a negative predictive value. In addition, both unilateral and bilateral detection rates were sufficient. Accordingly, carbon dye may be a promising tracer and a considerable option, particularly for low-income countries.