Interdisciplinary Laparoscopic News From the European Society for Gynaecological Endoscopy
by Anja Herrmann, Rudy Leon De Wilde
Professor and Head of Department of Obstetrics, Gynecology and Gynecological Oncology, PIUS Clinic, Carl-von-Ossietzky-University Oldenburg, Germany (Rudy Leon De Wilde)
At the last congress of the ESGE, held in September 2012 in Paris, a broad spectrum of gynecological topics were presented containing a variety of presentations which could be of interest to laparoscopic surgeons of other specialties as well.
Laparoscopy continues to proliferate in volume and complexity in many hospitals all over the world. Despite the fact that the advantages of minimally invasive surgery are well known among surgeons, laparoscopy is still not implemented in all hospitals especially in the case of complex procedures.
Sautua et al. took a closer look at vascular complications in their series of 287 laparoscopic oncological procedures (191 hysterectomies (31 of them radical), 156 bilateral pelvic lymphadenectomies, 100 retroperitoneal and 29 transperitoneal aorto-cava lymphadenectomies). Additionally, they reported how they solved these complications. A total of 16 vascular complications (5.58%) were recorded: 6 vena cava (2 electrocoagulation, 1 clip, 3 Floseal®); 4 external iliac vein (3 clips and 1 suture); 2 ovarian artery (bipolar electrocoagulation); 1 left lateral aorta (Floseal®); 1 inferior mesenteric artery (coagulation and section); 1 right hypogastric vein (clip and Floseal®) and 1 right primitive iliac artery (bipolar coagulation). All vascular incidents occurred during lymphadenectomy and were resolved laparoscopically. Five patients required blood transfusions. Besides clips, sutures and electrocoagulation, the authors used a hemostatic agent to rapidly treat potentially life threatening vascular injuries .
A long-term evaluation of laparoscopic lymphocele fenestration with a total of 102 patients included was presented. The objective of this study was to evaluate laparoscopic lymphocele fenestration (LLF) as a first-line treatment in gynaecological cancer patients with a history of retroperitoneal lymph node dissection (LND). Main outcome measures included operating time, blood loss, conversion rate, intra- and post-operative complication rate, hospital stay and relapse rate. A total of 132 lymphoceles were fenestrated per laparoscopy. Mean duration of surgery was 115.6 minutes and the average intra-operative blood loss per patient was 146 ml. Overall conversion rate to laparotomy was 7.8 %. Intra- and postoperative complication rates were estimated at 9.8 % and 5.9 % retrospectively. The rate of intraoperative and postoperative complications was significantly higher in patients after pelvic plus paraaortic LND (23.8 %) compared to those after pelvic LND only (3.6 %; p<0.01). Mean follow-up time was 60.4 months and a total of seven symptomatic recurrences of lymphoceles were observed (recurrence rate: 6.9 %). LLF has been previously established as an efficient first-line treatment option in a post-transplant context. The presented data suggest that these favourable results for LLF may be transferable to (gynaecological) cancer patients .
Miranda et al. described a case of a 33 year-old woman who developed a compartment syndrome after surgery for deep pelvic endometriosis. In the immediate postoperative period, a tumescent erythematous area was observed and the patient experienced severe pain and paresthesias in the posterolateral compartment of the lower external limb. Fasciotomy was performed with a unique lateral incision that does not close. After 4 days, a revaluation revealed an area of decreased contractility of medial gastrocnemius muscle, so that the extirpation of the affected area and fasciotomy closure were performed. Anomalous positions, together with hypotension, hypovolemia and peripheral vasoconstriction as well as venous disorders or other risk factors such as obesity, can be a cause of this complication. Therefore, possible preventive measures should be implemented, such as control of the correct position of the limb, use of padded brackets, and avoidance of hypotension, hypovolemia and vasoconstrictor drugs. If a surgery with a duration of more than 4 hours is expected, legs should be moved at least every 2 hours .
Laparoscopic surgery appears to be less traumatic than open procedures but the risk of thrombosis after laparoscopic surgery is not well known. Fibrinolysis studies can stratify the thromboembolic risk in patients undergoing laparoscopy. One study analyzed the changes of systemic fibrinolysis in patients who underwent elective benign adnexal laparoscopic surgery (uni or bilateral cystectomy/adnexectomy). In 45 patients, blood samples were drawn on admission (S1), during surgery (S2) and on the first postoperative day (S3). Samples were evaluated for clot lysis time (CLT) and plasmin-alpha2-antiplasmin complexes (PAP) as global functional tests of fibrinolysis. No patient presented with thromboembolic events before or after surgery. CLT (minutes) was shorter in S2 although differences were only statistically significant between S2 and S3 (p=0.02) (S1:64.2±13.0; S2: 59.6±15.4; S3: 68.9±15.2). PAP was statistically higher in S2 compared to S1 (p=0.001) and S3 (p<0.0001) (S1:375± 190; S2:912±654; S3:296±153). Benign adnexal laparoscopy seems to transitionally activate plasma fibrinolysis. The pre and postoperative CLT was longer in older, multiparous and obese patients as well as in users of hormonal treatments. Hence, these patients should be considered to have a high thromboembolic risk .
Insertion of the first trocar is a critical step for safe laparoscopic surgery. Entry related injuries are rare, but potentially life threatening. Several techniques have been developed, none of which is exempt of complication therefore the root of access is still a matter of debate . The results of three studies dealing with different entry techniques were presented at the congress.
Markovic et al. presented a retrospective analysis of 1000 consecutive laparoscopies with direct trocar insertion (DTI) without prior establishment of pneumoperitoneum. Direct trocar insertion was carried out through elevation of anterior abdominal wall with the non-dominant hand and both assistants’ hands. Creation of pneumoperitoneum with DTI was feasible in 100 % of patients. There were no cases of technical failure or complications. The authors conclude that DTI at laparoscopy is an easy, fast and effective technique and a safe alternative to the Veress needle technique .
Trocars are the most named in malpractice injury claims associated with MIS. Differences in trocar related complications (TRCs) may be attributable to different trocar types and fascial closure. As part of the development of a multidisciplinary guideline on Minimally Invasive Surgery (MIS), Chapelle et al. formulated evidence based recommendations for trocar use and fascial closure of trocar sites. The problem analysis and literature review revealed clinical heterogeneity in trocar use and fascial closure. A meta-analysis of RCTs concluded that the use of radially expanding access (REA) vs. cutting trocars leads to fewer trocar site bleedings (TSB). For secondary ports the use of REA vs. cutting trocars resulted in decreased postoperative pain. A retrospective study showed non-cutting vs. cutting trocars lead to fewer TSBs and trocar site herniation (TSH). No studies showed a reduced risk for TSH after fascial closure. Two retrospective studies found increased prevalence of TSH in 12 mm vs. 10 mm ports. To reduce the risk for TRCs, the authors recommend to use non-cutting trocars for 10–12 mm ports and to close the fascia of trocar ports >10 mm. Fascial closure of smaller ports could be considered .
Another important aspect to further promote the implementation of laparoscopy is the development of appropriate training programs and instruments. As working hours decrease, training at home has the potential to help improve psychomotor skills outside the operating theatre or skills laboratory. Laparoscopic suturing is difficult to master, involving depth perception, visuospatial awareness, coordination, fine motor skill, and non-dominant hand use. Suturing can be divided into several steps requiring different techniques, and is often considered a marker of proficiency in laparoscopy. 30 students with no prior experience enrolled on a single day laparoscopic skills course, ending with the ability to suture. A video simulator was provided for use at home over a 6-week period, with access to online videos. Suturing was timed on day 1 and week 6, and correlated with the amount of practice. Mean suture time at the end of day 1 was 612.5 s (sd 294.2), and was significantly reduced to 433.9 s (sd 195.5) by week 6 (p<0.0001, paired t-test). The mean number of home simulator hours per week was 2.33 (sd 1.27), with a significant correlation between improvement and practice (Pearson 0.861, p<0.0001).This study demonstrates that simulation shortens the learning curve and improves psychomotor skills in laparoscopic suturing. It could be shown that the use of a video simulator at home significantly improves laparoscopic suturing skills, with a correlation between performance and practise .
Proficiency in advanced laparoscopic surgery cannot be appropriately monitored by economy of movement analysis in box trainers. Economy of movements of intracorporeal knot tying in laparoscopic box trainers can differentiate between novices, intermediates and experts. In search of predictive models for quality of care, the applicability of motion-analysis parameters of knot tying in box trainers in experts as predictors for surgical outcome was researched in a study. Time, path length and motion in depth of a standardized intracorporeal knot tying task were compared to average risk-adjusted primary outcomes (blood loss and operative time) of a one year consecutive analysis of laparoscopic hysterectomies. Surgical outcomes were corrected for patient factors. Experience with laparoscopic hysterectomy correlated with efficient knot tying in the box trainer. After correction for patient mix in 50 expert surgeons, motion-analysis of intracorporeal knot tying could not significantly discriminate surgical outcome skills in advanced laparoscopic surgery. Instead, monitoring of real-time risk adjusted surgical outcomes of experts was suggested .
Adhesions are still an unsolved problem in abdominal surgery including not only laparotomy but also laparoscopy. Dubinskaya et al. searched for endogenous and exogenous risk factors of adhesions. The aim of the endogenous risk factor study was to evaluate clinical markers of connective tissue dysplasia (DCT) in patients with pelvic peritoneal adhesions. 200 patients with laparoscopically verified pelvic adhesions were included in the study. 35 patients without adhesions were recruited as the control group. Among patients with I-II stage of adhesions compared to patients with III-IV stages clinical manifestations of DCT included scoliosis (28.4 and 62.4 %), platypodia (50.7 and 88 %), disorders of growth and density of teeth (32.8 and 58.6 %), thin and easily damaged skin (34.3 and 55.6 %), multiple pigmented spots (13.4 and 26.3 %), kelloid scars (23.9 and 48.1 %), myopia (38.8 and 64.6 %), hematoma formation after minimal damage (37.3 and 77.4 %), varicose veins (12 and 36.8 %). The data suggest that patients with severe and moderate stages of pelvic adhesions have more connective tissue disorders external manifestations compared to patients with minimal and mild stages and the control group. One patient with stage III-IV adhesions had 6 and more phenotype stigmas of connective tissue disorders (unclassified phenotype). The results proved the role of genetic factors in pelvic adhesion formation and connective tissue disorders as endogenous risk factor of pelvic adhesion formation .
The objective of the exogenous risk factor study was to analyze the risk factors affecting adhesions formation and to see how they relate to their stage. 1000 hospital discharges in a gynaecological department from the most recent data (2008-2011) were analyzed. 752 women were discharged with a diagnosis that included the specific diagnosis of pelvic adhesions. Among them 372 (49.5 %) patients had previous surgery and 355 (47.2 %) patients had pelvic inflammatory disease. 79 factors connected with previous surgery and 57 factors connected with inflammation were evaluated. Significant risk factors of pelvic adhesions formation connected with surgery were determined: types of surgery (myomectomy (f=0,478, p<0,01), adhesiolysis (f=0,455, p<0,01)), laparotomy (f=0,439, p<0,01), repeated surgeries (f=0,355, p<0,01), peritoneal drainage (f=0,324, p<0,01), emergency of previous surgery (f=0,219, p<0,01) and inflammation: sexually transmitted infections (f=0,854, p<0,0001), IUD using (f=0,337, p<0,01), 2 and more abortions (f=0,432, p<0,01), pregnancy complications connecting with pelvic inflammatory diseases (f=0,641, p<0,01). These results could be useful for preoperative evaluation of adhesion stage as an addition to physical and ultrasound examination. Surgery that includes aggressive risk factors needs antiadhesions barrier usages .
Conditioning of pneumoperitoneum (PP) not only reduces postoperative adhesions but also reduces tumor implantation in a laparoscopic mouse model. Tumour implantation increases following 60 min pneumoperitoneum using standard dry CO2. This was prevented by full conditioning. A study aimed to demonstrate the damaging effect of dry CO2PP and the beneficial effect of the conditioning upon tumor implantation in a laparoscopic model. Experiment 1: dose response curve with the tumor cell line CT-26 in control groups (without surgery) and in mice with 60 min dry CO2 PP. Experiment 2: cells were injected in control group without surgery (I) or after a 60 min PP (II to VI). To the dry CO2 group (II), humidification (III), 10 % N2O (IV), 4%O2 (V) and cooling (VI: conditioning) were sequentially added. In experiment 1, tumors increased after dry CO2 PP in both abdominal cavity (p=0.018) and on the wall (p<0.0001). In experiment 2.60 min of dry CO2 PP confirmed the tumor increased in the abdominal cavity (I vs. II: p=0,026) which was dropped by full conditioning (II vs. VI: p=0.030). For the abdominal wall, tumors increased by 60 min dry CO2 PP (I vs. II: p=0,003) and this was reduced using humidified CO2 (II vs. III; 0.032) or conditioning (II vs. VI: p=0,026). Similar to the observations made for adhesion formation, tumour implantation increases following a 60 min of dry CO2 PP, and this was prevented by full conditioning. A less traumatic PP during laparoscopic oncological surgery is possibly beneficial .
Obesity compromises laparoscopic access to the pelvic and complicates many surgical procedures. Its influence on lymph node yield and mean hospital stay were analyzed in a series of 152 bilateral pelvic lymphadenectomies. 152 pelvic lymphadenectomies between October 2007 and December 2011, in combination with other oncologic procedures were performed. Patients were divided into 2 groups according to BMI, using 26 as a cut-off point (Group A: BMI≤26; Group B: BMI>26) and results were compared (Group A vs. Group B). Data were collected prospectively. Results: number of patients (79 vs. 73); mean age (56.73 vs. 64.83), mean stay (4.39 vs. 4 days), mean BMI (23.19 vs. 31.71 kg/m2), total LN (1054 vs. 959) and mean LN (13.34 vs. 13.32). However, the results support the feasibility of laparoscopic pelvic lymphadenectomy in obese patients. No differences in lymph node yield or hospital stay when comparing obese patients with those with a BMI<26 were found. Surgical times could not be compared due to the additional procedures performed in many of the patients. Obesity does not influence the outcome of bilateral pelvic lymphadenectomy .
Obese patients pose also a challenge to transperitoneal paraaortic lymphadenectomy. The influence of obesity on the results of retroperitoneal aortocava lymphadenectomy (RACL) was analyzed in a series of 102 consecutive patients. Between May 2008 and December 2011 102 RACL for gynecological cancer were performed. Patients were divided into 2 groups according to BMI, with a cutoff point of 26 (Group A: BMI≤26; Group B: BMI>26) and results were compared (Group A vs. Group B). Results: number of patients (49 vs. 53), mean age (56.21 vs. 67.02 years), mean LN number (13 vs. 13), mean hospital stay (4.33 vs. 4.29 days), mean BMI (23.21 (range: 19-26) vs. 32.31 (range: 27-41)). It was observed that the number of periaortic lymph nodes was equal in both groups, which suggests that obesity may not influence results in terms of adequate dissection and number of LN obtained. Patients in group A were on average 10 years younger than those in group B. This reflects the correlation between increasing age and obesity, as well as the greater prevalence of cervical cancer in this group, for which obesity is not an important risk factor. In conclusion, obesity does not compromise the results of retroperitoneal aortocava lymphadenectomy for gynecological cancer and should therefore be the first choice for aortocava lymphadenectomy in obese patients .
Robotic surgery is increasingly implemented as an alternative minimally invasive approach. A huge drawback of robotic surgery are the high costs associated with this technique. Consequently, suggestions to reduce this cost were made. The objective of a study was to analyze the feasibility of a new robotic operative room set-up to reduce the costs for endometrial cancer treatment. 22 endometrial cancer patients undergoing robotic surgery were enrolled in the study from June 2010 to April 2012. They were divided in 2 different approaches (A: standard, B: modified) in relations to numbers of operative robotic arms, OR staff composition (nurses, non-nurses, surgeons, anesthetists), disposable and non-disposable instruments. Comparison of costs and feasibility between the 2 groups was performed. 8 patients were treated with standard robotics approach (A) with 4 robotic arms;14 women with the modified approach (B) with 3 robotic arms, reduction of disposable laparoscopic instrumentation and OR staff. Pelvic lymphadenectomy was performed in 14 cases (5 in group A, 9 in group B). Median operative time in group A was 214 min (157–265), in group B 185 min (126–219). No intra or postoperative major complications occurred in both groups. Median hospital costs per intervention (excluding robotic surgical system cost) were in group A 8.858 €, in group B 7.244 €, with a reduction of 18 %. The costs of robotic surgery are mainly related to the purchase and maintenance costs. It was demonstrated that they can be reduced by increasing the number of interventions and adopting a modified approach .
As robotic surgery will likely remain a costly procedure in the near future, new techniques to improve conventional laparoscopy are developed. Berkes et al. introduced an innovation, the KYMERAX® system, which combines the advantages of conventional laparoscopy and robotics. KYMERAX® is a motor-driven hand-held device that comprises a console, handles, and instruments and provides articulation at the tip. In addition to the four degrees of freedom of conventional laparoscopy, it offers two additional degrees of freedom: a yaw movement to the left and right in 70 degrees and a rotation in 320 degrees. The system enables easier manipulation of target tissues in hard-to-reach areas, provides haptic sensation, and is compatible with conventional instruments. The authors state that the system with its advantages and lower costs fills the gap between conventional laparoscopy and high-end robotics and, thus, is ideally suited to daily clinical use .
The objective of another study was to test the clinical feasibility of a novel concept of robotic instrument to overcome the difficulties of conventional laparoscopy in multiport and single port laparoscopic surgery. The tested instrument (JAiMY-5mm motorized articulated needle driver) offers two motorized distal degrees of freedom: bending of the shaft to adjust needle positioning into the appropriate plane and unlimited axial rotation of the end effector to drive the needle through the tissue, while keeping an outer diameter of 5 mm. In this study, the instrument has been used in human in a multiport myomectomy and for the first time in a single port sacralcolpopexy. Use of this robotic instrument has proven feasible for suturing the uterine wall and the anterior and posterior prosthetic band, with a better compliance with suture lines. The combination of distal shaft bending and rotation of the end effector makes these sutures easier and improves the surgeon's posture by reducing the movement of shoulder abduction. JAiMY has allowed increased triangulation and precise control of the needle during suturing in any plane .
Several authors present their experience with a new 5mm device that combines advanced bipolar and ultrasound energy for dissection, sealing and cutting in laparoscopic surgery (Thunderbeat®). It is an integrated hand instrument that delivers the benefits of both advanced bipolar and ultrasonic energy in a single device. The ultrasound energy, well known for its dissection and cutting properties, is combined with advanced bipolar energy producing a sealing of vessels up to 7 mm diameter. This device has been shown to have better sealing abilities in comparison to a sole ultrasonic device and faster dissection time than an advanced bipolar device [18–20].
1. Ruiz Sautua R, Avlia Calle M, Goiri Little C, Martinez Gallardo L, Jaunarena Marin I, Bernal Arahal T (2012) Vascular complications in laparoscopic oncologic surgery. Gynecol Surg 9(Suppl 1):S92-S93
2. Marc R, Diebolder H, Anke M, Julia A, Runnebaum IB (2012) Laparoscopic lypmphocele fenestration in gynaecological cancer patients. Gynecol Surg 9(Suppl 1):S100
3. Fernandez Miranda E, Barri Soldevilla P, Cardenas Nylander C, Cusido MT, Ubeda A (2012) Compartment syndrome in deep endometriosis surgery. Gynecol Surg 9(Suppl 1):S35
4. Martinez-Zamora M, Tassies D, Reverter JC, Balasch J, Carmona F (2012) Activation of fibrinolysis during benign adnexal laparoscopic surger. Gynecol Surg 9(Suppl):S49
5. Bernal Arahal T, Goiri Little C, Ruiz Sautura R, Avlia Calle M, Lekuona Artola A, Martinez Gallardo L (2012) Our experience with open laparoscopic entry. Gynecol Surg 9(Suppl 1):S46
6. Markovic R, Vuckovic L, Stameric V (2012) Direct laparoscopic trocar insertion without prior pneumoperitoneum. Gynecol Surg 9(Suppl 1):S15
7. La Chapelle C, Jansen FW (2012) How to prevent trocar-related complications: trocar use and fascial closure. Gynecol Surg 9(Suppl 1):S2
8. Harrity C, O'Sullivan R, Prendville W (2012) Effects of a home-based simulation programme. Gynecol Surg 9(Suppl 1):S29
9. Andries T, Ellen H, Elzelyne B, Van Zwet E, Cor DK, Willen JF (2012) Intracorporeal knot tying in a box trainer as predictor of surgical outcome in advanced laparoscopic procedures: how proficient in vitro evaluation in experts. Gynecol Surg 9(Suppl 1):S29-S31
10. Dubinskaya E, Gasparov A, Barabanova O (2012) Connective tissue dysplasia manifestations in patients with pelvic peritoneal adhesions. Gynecol Surg 9(Suppl 1):S62
11. Dubinskaya E, Gasparov A, Lapteva N (2012) Exogenous risk factors of pelvic adhesions. Gynecol Surg 9(Suppl 1):S63
12. Binda MM, Corona R, Amant F, Koninckx P (2012) Conditioning of the abdominal cavity reduces tumor implantation in laparoscopic mouse model. Gynecol Surg 9(Suppl 1):S86
13. Ruiz Sautua R, Avlia Calle M, Goiri Little C, Lekuona Artola A, Martinez Gallardo L, Bernal Arahal T (2012) Influence of obesity on bilateral pelvic lypmphadenectomy. Gynecol Surg 9(Suppl 1):S87
14. Goiri Little C, Bernal Arahal T, Ruiz Sautua R, Avlia Calle M, Goyeneche Lasaga L, Martinez Gallardo L (2012) Influence of obesity on retroperitoneal aortocava lymphadenectomy. Gynecol Surg 9(Suppl 1):S87
15. Mereu L, Carri G, Arena I, Khalifa H, Zampetoglou T, Mencaglia L (2012) Cost analysis of robotic surgery for endometrial cancer: how to reduce costs. Gynecol Surg 9(Suppl 1):S101
16. Berkes E, Hackethal A, Oehmke F, Tinneberg H (2012) KYMERAX®: An innovation in robotic surgery. Gynecol Surg 9(Suppl 1):S102
17. Agostini A, Marcelli M (2012) Feasibility study 5mm motorized articulated needle driver. Gynecol Surg 9(Suppl 1):S136
18. Francx M, De Vree B (2012) First experience with a new 5mm device that combines advanced bipolar and ultrasound energy for dissection sealing and cutting in laparoscopic surgery. Gynecol Surg 9(Suppl 1):S126
19. Istre O, Springborg H (2012) Laparoscopic hysterectomy in cervical fibroids. Gynecol Surg 9(Suppl 1):S124
20. Jan H, Araklitis G, Narvekar N (2012) A video of laparoscopic hysterectomy using the new Thunderbeat®. Gynecol Surg 9(Suppl 1):S114