Interdisciplinary Laparoscopic News From the European Society for Gynaecological Endoscopy
by Anja Hirschelmann and Rudy Leon De Wilde
Professor and Head of Department of Obstetrics, Gynecology and Gynecological Oncology, PIUS Clinic, Oldenburg, Germany (Rudy Leon De Wilde)
At the 22nd Annual Congress of the European Society of Gynaecological Endoscopy (ESGE), held in October 2013 in Berlin, 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. This includes the management of well-known and rare complications, innovations in instrumentation and surgical techniques as well as the investigation of teaching and training laparoscopic surgery.
Management of complications
Adhesions are the most frequent complications after abdominopelvic surgery. Many efforts have been made to develop and prove comprehensive adhesion reduction strategies. However, there is still a need for effective and safe agents to use alongside optimal surgical technique. A study was conducted to explore the safety, manageability and usability of the new site-specific, sprayable ADBLOCK system. ADBLOCK is a novel bioresorbable gel composed of dextrin derivative and trehalose, which does not contain any colorant, however this allows excellent visualization on the operative field. 32 patients, undergoing laparoscopic de-novo removal of myomas were randomized (2:1) to be treated with either the ADBLOCK (21) sprayed over all myomectomy sutures or with surgery only (11). Primary endpoint was the assessment of serious adverse events (SAE) up to 28 days. SAEs rate was 5% and 10% in ADBLOCK and control arm respectively. Two scheduled second look laparoscopies (one patient in each arm) were the only serious adverse events documented, following protocol definitions. Any adverse events were recorded in 7 and 11 patients, respectively. The main events reported were postoperative pain, nausea, vertigo, discomfort, and dysmenorrhea. There were no post-operative infections. No further adverse events were reported between 28 days and 6 months. The results of the study showed a good safety profile for the ADBLOCK adhesion barrier .
Adhesion formation at surgical sites is enhanced by factors from the entire peritoneal cavity driven by acute inflammation. N2O has advantages over CO2 for the pneumoperitoneum (PP) since it has lower irritative effects, less metabolic side effects and less postoperative pain. N2O is a safe gas given the high solubility in water and diffusion in the lungs similar to CO2. N2O however has an explosion risks at concentrations higher than 29%, and thus was not used. In a laparoscopic mouse model and in a mouse model for open surgery the effect of N2O in different concentrations upon pneumoperitoneum and surgical gas environment enhanced adhesion formation was investigated. In open surgery, adhesions decreased with concentration of N2O in humidified CO2 with a maximal effect adding 10% of N2O (P= 0.0006). In laparoscopic surgery, dose response curves demonstrated that the addition of 5%, 10%, 25%, 50% and 100% of N2O to the CO2 PP strongly decreased the proportion of adhesions in all groups (P=0,0001). Therefore, N2O from concentrations of 5% onwards is the most effective prevention of adhesion formation both during laparoscopic surgery and in open surgery. Furthermore, N2O in concentration of 5 to 10% is safe since N2O is highly soluble in water as CO2 is, while the explosion risk does not exist below 30% .
A case report presents the laparoscopic removal of a 16-year-old postoperative foreign body of the pelvis complicated by injury of the right internal iliac vein which was managed with endoscopic suturing. A 24 year old woman complained from abdominal pain within a year after the first birth. She had laparotomies at the age of 6 and 8 due to vesicoureteral reflux. Ultrasound showed an 8 cm right pelvic mass attaching the sidewall up to internal inguinal ring. Postoperative surgical gauze retained in the pelvis for 16 years was suspected which is a rare iatrogenic complication. Its removal is associated with significant technical difficulties to avoid intestinal, ureteric and vascular injuries as such masses are surrounded by fibrotic tissue and can be located deep in the pelvis. The fibrotic tissue makes it difficult to find the cleavage planes to remove the mass. In the case presented, the complication of a 2 mm injury of a vessel wall identified as internal iliac vein was successfully managed with intracorporeal suturing. The patients postoperative course was uneventful. Thus, laparoscopic approach to pelvic retroperitoneal masses can be feasible, even in the cases of previous surgery .
Another case was reported where the blade of a needle holder broke and got lost during the repair of a uterine defect in the course of a laparoscopic myomectomy procedure. The operation took place in a small nursing home where no facilities for C-arm, portable x-ray machine or magnetic forceps existed. After futile efforts to trace the broken blade under direct vision, the lost piece was finally recovered laparoscopically with the help of a small magnetic piece that was bought and sterilized by keeping it in cidex solution. The piece was tested on the needle holder outside the patient’s body to see whether it was effective. It was held with a grasper and introduced inside the patient’s body through the port used for morcellator. As soon as the magnetic piece held in with a grasper that was put inside the patient’s body the lost piece of the instrument came out of nowhere and got stuck to the magnetic piece. It was then removed under direct vision. This was an unexpected complication which was difficult to manage in a small nursing home set up .
A case of idiopathic brachial plexus neuritis (IBN) following laparoscopic excision of endometriosis was reported as the differential diagnosis between this non-position-related neuritis and brachial plexus injury is challenging. IBN was reported in 1948 by Parsonage and Turner and presents with shoulder girdle pain followed by profound weakness. The syndrome is of unknown etiology and has been described as a potential postoperative complication. In the postoperative patient the appearance of IBN symptoms may lead to misdiagnosis as they can be attributed to brachial plexus injury (BPI) due to perioperative patient positioning as well. A 37-year-old woman underwent laparoscopic excision of endometriosis. The operation was performed in Trendelenburg position, the patient’s head was kept in a neutral position and her arms were placed straight by her side. After an initially uneventful recovery, clinical examination revealed wasting and weakness of the infraspinatus muscle i.e. likely isolated suprascapular nerve palsy in keeping with IBN. Magnetic resonance imaging showed atrophy of supraspinatus and infraspinatus left shoulder muscles without evidence of nerve compression. Nerve conduction studies confirmed the diagnosis of IBN. Recovery was enhanced with physiotherapy. IBN may complicate laparoscopic surgery as it can be transiently debilitating for the patient and distressing for the surgeon, with potential medico-legal implications if misdiagnosed as BPI. The diagnosis must be based on history, clinical examination, absence of evidence of nerve compression in MRI and confirmation by electromyographic studies .
Innovation in instrumentation and surgical techniques
Trocar dislodgement is a common problem complicating laparoscopy. Trocar stabilization methods have been vigorously investigated in order to minimize this risk contributing thus in patients’ safety, but also in reducing procedural time and increasing surgeon’s satisfaction. A non-blinded, prospective study to evaluate the effects of utilizing a fixator to control mobility of trocars in operative laparoscopy was conducted. The aim of this study was to evaluate trocar stability using a fixation device aimed at controlling trocar insertion depth but especially providing greater stability during laparoscopic procedures. 43 patients received laparoscopic interventions longer than 10 minutes. 5mm working trocars were used bearing a plain sleeve. The fixator device was attached to one of the two side trocars prior to insertion. In 18 patients an unsutured fixator was used (FX-US-subgroup). In 25 patients the device was sutured to the skin through specially suturing ports (FX-S-subgroup). Position of both trocars was evaluated at the start of the procedure and every 10 minutes intraoperatively. The FX-group showed significantly decreased trocar movement compared to NFX-group (0.02 to 0.6 cm vs. 0.84 to 4.4 cm). In the NFX- group, the trocar showed a tendency to slip into the abdomen and in the FX-group to slip out. 11 of 43 ports (25.6%) were reinserted or readjusted. The use of fixator thus significantly reduces plain (smooth) sleeve trocar movement, prohibits a complete dislocation or slippage of the port, while suturing the device to the skin further minimizes trocar movement. The fixation device may lead to a shorter operation time and reduce problems associated with trocar slippage or dislocation .
Abdominal access gas delivery using hollow tubes causes pressure drops, restricted distribution and high terminal velocity flow. A newly designed Synergy cannula corrects and improves these conditions. The physical structure and design of cannulas used for peritoneal access determine the distribution and parameters of gas flow. To date all cannulas for laparoscopic gas delivery are hollow tubes with gas entering the top and exiting the bottom. The side walls are continuous uninterrupted and smooth creating a characteristic physical and gas distribution signature due to its design. It was hypothesized that a newly designed cannula with perforations would show a difference. Testing and analysis was done comparing available trocar/cannulas (Ethicon, Covidien, Applied Medical) with the LEXION Medical Synergy Port. Insufflators used were Storz Thermoflator, Olympus UHI-3 and Stryker Pneumosure. Gas distribution pattern for traditional trocars was circular, unidirectional and constricted covering 1% of the pneumoperitoneum. The Synergy covered 92%. Statistically significant findings (p 0.01) were higher flow rates (78% improvement), lower pressure drop (70% improvement), higher pressure to prevent seal failure (84% improvement), higher maximum flow (42% improvement), time to create a pneumoperitoneum (84% improvement) and gas terminal velocity (35% lower) using the Synergy Port compared to the others. Thus, changing the design of a hollow tube cannula to one having internal grooves and multiple distal perforations significantly improves gas flow characteristics and flow rate, has higher pressure to seal failure, higher maximum gas flow, decreased time to create a pneumoperitoneum, lower gas terminal velocity and 99% gas dispersion pattern [7,8].
Surgeons are always interested in new innovations in surgical equipment especially if it can give better access and angle of approach to blood vessel sealing. A video was shown containing the world's first laparoscopic hysterectomy performed with the new Enseal Lap G-2 Articulating device. This was the very first surgical case utilizing the new Enseal Lap G-2 Articulating energy device to perform a total laparoscopic hysterectomy on a difficult fibroid uterus where over a dozen fibroids were present. The biggest challenge was a low anterior segment large fibroid. The articulation was essential in access to the vessels. Three 5mm trocars, one 12mm trocar, Enseal Lap G-2 Articulating device and the new Sigma morcellator were used. Surgery took about 90 minutes and blood loss was less than 50cc. The patient did quite well and was discharged two hours post operatively. Articulating energy devices will be invaluable for difficult laparoscopic gynecological surgeries, single site surgeries as well as other appropriate laparoscopic general surgeries. The device performed as well as if not better than the regular Enseal Lap G-2 device. .
The quasi-utopic whish of enthusiastic supporters of minimally-invasive surgery is to perform scarless operations. Single-site laparoendoscopic surgery (SILS) has used the umbilicus to perform a vast variety of gynaecological procedures. One of the downsides of SILS is that this technique can leave a non-cosmetic result in the woman’s umbilicus. The first description of a series of minilaparoscopic single umbilical incision total hysterectomy using two 3mm-umbilical accesses and no further skin incisions was presented. Five nulliparous women operated for benign conditions were selected for the study. A Rumi manipulator with a Kho colpotomizer cup was inserted in all cases to expose uterine supportive structures. Median operative time was 40 (range 35-55) minutes. Blood loss was negligible. No conversion to conventional laparoscopy or laparotomy and no intra or postoperative complications occurred. Median postoperative pain 8 hours postoperatively was 0 (range: 0-4) using a VAS score. Hospital stay was less than 24h for all patients. The preliminary experience with minilaparoscopic single umbilical incision total hysterectomy shows that, in the hands of an experienced minimally-invasive surgeon, this operation is feasible in selected patients. Further research is needed to prove the real feasibility and the possible (if any) advantages of this procedure .
Operations using exclusively 2-mm instruments have been reserved by gynecologic surgeons only to diagnostic purposes. A first series of consecutive salpingo-oophorectomies entirely performed microlaparoscopically were presented. Since 1993 several studies about microlaparoscopy have been published; however, none of these regarded gynecologic operative procedures using only 2-mm extraumbilical ports. Five consecutive women with molecular diagnosis of BRCA1-2 were enrolled. A 3-mm trocar was introduced intraumbilically. Right and left suprapubic 2-mm ancillary trocars were inserted under vision. For right adnexectomy, a 2-mm scope and grasper were used. Median operative time was 35 minutes (range 30-50). Neither conversion to conventional laparoscopy nor to open surgery was needed. No intra-operative complications occurred. Estimated blood-loss was less than 10cc for each procedure. No post-operative complications were reported 1 month after surgery. All patients were discharged the same day of surgery. The authors stated that the first experience with 2-mm operative laparoscopy appears encouraging but they also believe that this technique should be reserved to skilled laparoscopic surgeon. The advantages may include faster return to every-day activities, more comfortable postoperative recovery and satisfactory aesthetic outcomes with possibly better results compared to the traditional laparoscopy .
The combination of laparoendoscopic single-site surgery (LESS) and the da Vinci Single-Site robotic surgical platform seems to be a promising choice to overcome the technical difficulties of LESS. An initial experience of five procedures of robotic single-incision transumbilical total hysterectomy and bilateral salpingo-oophorectomy using the da Vinci Single-Site Platform was presented. The docking time and console time were 6 minutes and 116 minutes, respectively. Estimated blood loss was 66 ml and uterine weight was 150 grams. The postoperative course was uneventful. All patients were pleased with the cosmetic appearance of the umbilicus. Robotic-assisted single-incision transumbilical total hysterectomy and bilateral salpingo-oophorectomy is feasible, especially in selected patients. Further experience and technical refinements will improve operative results. Further work is needed to advance the single-site robotic platform, the articulation of the instruments and the instrumentation using bipolar energy .
Teaching and training
The purpose of the presented study was to assess the effect of a computer based virtual reality surgical simulator and a traditional box trainer (BT) on an actual laparoscopic operation, and to determine whether one has an advantage over the other. Forty first and second year residents were randomized into either LapSim or box trainer group. Twenty senior residents were allocated to the control group. The first and second groups trained on LapSim and BT, respectively, for four weeks. Both groups performed laparoscopic bilateral tubal ligation. Video records of each operation was assessed using general rating scale of objective structured assessment of laparoscopic salpingectomy (OSA-LS) and operation time in seconds. The LapSim group and the BT group performed significantly better in total score and time when compared with the control group. But there were no differences between LapSim and BT group. Therefore, novice residents trained on a computer based VR simulator or BT performed better live laparoscopies as compared to residents trained in standard clinical surgical education. Both the VR simulators and box trainers are thus more effective than classic surgical education by means of basic gynecological procedures. Consequently, training with either a VR simulator or a BT should be considered before trainees carry out laparoscopic procedures and training hospitals should construct a laparoscopic training laboratory .
Although there are training programs for development of oncological gynecological skills, the day-to-day theatre activity is more challenging. Surgeons need extensive practice to learn the correct techniques. Even though the development of fellowship programs provide professional skills, it is not enough to face the responsibility as a main surgeon. A training method of oncological gynecological surgery for achieving a faster and safe learning curve was presented. In 2011, a new community public hospital was set up in Madrid. Although there was a vast expertise in laparoscopic surgery, there was a lack of experience in oncological gynecological surgery as main surgeon. After a detailed economical and quality analysis, hospital’s management arranged senior oncological laparoscopic surgeons to assist and train its oncological surgeon, only during the procedure, instead of referring patients to specialized hospitals. The postoperative period was managed by the hospital’s medical team. From October 2011 to May 2013, 24 patients (14 endometrial and 10 cervical cancers) were operated by laparoscopy. Senior surgeon trained his colleagues in 3 paraaortic lymph node dissection procedure and in 2 radical hysterectomies. The rest of the surgeries were performed by the hospital team. No major complications occurred. The learning curve period was short and safe. This method is more comfortable than and as safe as training performed in specialized hospitals .
1. De Wilde RL, Ziegler N, Korell M, Tchartchian G. Safety evaluation of the new sprayable adhesion barrier ADBLOCK system after laparoscopic de-novo myomectomy. Gynecol Surg (2013) 10 (Suppl 1): S98
2. Corona R, Binda MM, Koninckx P. The effect of 10% of N2O upon adhesion formation in laparoscopic and open surgery. Gynecol Surg (2013) 10 (Suppl 1): S32
3. Ogurtsov A, Vedeneeva N, Maltsova J, Naurbieva M, Komlev D. Laparoscopic removal of retroperitonal postoperative foreign body of the pelvis. Gynecol Surg(2013) 10 (Suppl 1): S74-75
4. Agarwal M. The lost surgical instrument, a surgeon’s nightmare and a novice method to resolve the complication. Gynecol Surg (2013) 10 (Suppl 1): S135
5. Minas V, Aust T. Idiopathic brachial plexus neuritis vs brachial plexus injury following laparoscopy. Can you spot the difference? Gynecol Surg (2013) 10 (Suppl 1): S13
6. Vrentas V, Cezar C, Herrmann A, Diesfeld P, De Wilde RL. Reducing trocar movement in operative laparoscopy through the use of a fixator. Gynecol Surg (2013) 10 (Suppl 1): S19
7. Ott D. Cannula dynamics of the Synergy port for laparoscopy. Gynecol Surg (2013) 10 (Suppl 1): S81
8. Ott D. Gas distribution, pressure drop and pneumoperitoneum comparing traditional cannulas to a new cannula port (Synergy). Gynecol Surg (2013) 10 (Suppl 1): S81
9. Kondrup J. Laparoscopic hysterectomy for large uterus: world’s first case with articulating Enseal. Gynecol Surg (2013) 10 (Suppl 1): S131
10. Uccella S, Casarin J, Cromi A, Rossi T, Sturla D, Carollo S , Ghezzi F. Mini-laparoscopic single umbilical incision total hysterectomy: a scarless way to remove the uterus. Gynecol Surg (2013) 10 (Suppl 1): S35
11. Casarin J, Uccella S, Cromi A, Podestà AC, Candeloro I, Ghezzi F. Two-millimeters operative microlaparoscopic salpingo-oophorectomy: a case series of 5 procedures. Gynecol Surg (2013) 10 (Suppl 1): S35-36
12. Akdemir A, Sendag F, Öztekin K. Robotic single-incision transumbilical total hysterectomy using a single-site robotic platform. Gynecol Surg (2013) 10 (Suppl 1): S71
13. Akdemir A, Sendag F, Öztekin K. Laparoscopic virtual reality and box trainer in gynecology: a prospective, randomized, controlled, and blinded study. Gynecol Surg (2013) 10 (Suppl 1): S92
14. Gonzales Gea L, Santacruz MB, Perez MI, Martinez Campo D, Garbayo SP, Brik M, Cristobal MI. Laparoscopic oncological surgery training: a new strategy. Gynecol Surg (2013) 10 (Suppl 1): S28