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Laparoscopic Resection of Rectal Endometriosis
S18
Abstracts / Journal of Minimally Invasive Gynecology 15 (2008) S1eS159
is surgically removed resulting in optimal mass reduction. Hysteroplasty is also much easier because tension free reapproximation is possible. We use mattress for superficial layer reapproximation which make the wound edge inverted. As a result we can prevent adhesion and wound bleeding. The laparoscopic Convex lens resection method is simple, easy to perform and optimal adenomyotic tissue reduction is possible compared to usual adenomyomectomy.
63
Video Session 3dEndometriosis (3:05 AM d 3:13 AM)
The Pelvic Autonomous Nerves: Surgical Anatomy in Radical Laparoscopic Excision of Endometriosis Pereira RMA, Zanatta A, Fonseca J III, Serafini P, de Paula FF, Preti CCL. Pelvic Surgery, Huntington Centro de Medicina Reprodutiva, Sao Paulo, SP, Brazil Deep infiltrating endometriosis treatment requires major retroperitoneal dissection. The pelvic autonomous nerves are at risk of injury because of their close relationship to the deep infiltrating lesions. Morbidity may be great, including bowel and bladder dysfunction. From the period of January 2006 to January 2008, 280 consecutive patients were submitted to laparoscopic radical excision of endometriosis, including bowel resection in 84 cases, at two private health services in Londrina and Sao Paulo, Brazil. Pelvic autonomous nerves isolation was systematically performed, according to the area involved by disease. On this video, we demonstrate the anatomy of the superior hypogastric plexus, the inferior hypogastric nerves, the inferior hypogastric plexus and its three main efferent bundles. We review their visceral function, topography and anatomic relation to pelvic organs and major structures. The objective of the video is to improve knowledge in pelvic neuroanatomy for a proper nerve-sparing surgical technique.
64
Video Session 3dEndometriosis (3:14 AM d 3:19 AM)
Laparoscopic Excision of Endometriotic Bladder Nodule and Repair of Cystotomy Kung RC, Liu G, Lie K. Obstetrics and Gynecology, Women’s College Hospital, Toronto, Ontario, Canada Endometriosis involving the bladder is not common. It may present with cyclic hematuria as well as pelvic pain. This may be palpable vaginally, anterior to the cervix. On cystoscopy, there is mucosal edema and nodularity. Occasionally, it can be misdiagnosed as a malignancy on ultrasound due to its irregular appearance. Laparoscopic excision with simultaneous cystoscopic visualization will minimize the risk of cystotomy. Complete excision is recommended to obtain relief of symptoms. CO2 laser is the preferred modality. Ureteral stents may be necessary if the lesion is in close proximity to the ureteric orifices.
65
Video Session 3dEndometriosis (3:20 AM d 3:27 AM)
Laparoscopic Resection of Rectal Endometriosis Roman H, Tuech JJ, Marpeau L. Gynecology and Obstetrics, University Hospital Rouen, Rouen, France We aim to present our procedure of laparoscopic management of rectal endometriosis. The first stage starts by the dissection of ureters, followed by unilateral section of involved uterosacral ligaments. Pararectal spaces are opened toward lateral limits of the nodule, then dissection of inferior limit is performed until the elevator muscles of the rectum, toward the rectovaginal space under the nodule. The mesorectum is then sectioned. In the second stage, the nodule is sectioned in an anterior and a posterior fragments. The anterior fragment will be removed with the adjacent vagina, and the posterior one with the adjacent rectum. The third stage is performed by the digestive surgeon. The rectum is sectioned using GIA stapler and pulled out through a paraombilical incision. Rectosigmoidal resection is done transparietally. Anastomosis is done laparoscopically
using transanal stapling device PCEA. The omentoplasty and ileostomy are done to prevent rectovaginal fistulae. Ileostomy is closed 2 months later.
66
Open Communication Session 1dEndoscopic Techniques (3:35 PM d 3:40 PM)
Retroperitoneal Lymphadenectomy by N.O.T.E.S Technique in Porcine Model: Feasibility and Survival Study Nassif J,1 Zacharopoulou C,1 Perretta S,2 Dallemagne B,2 Marescaux J,2 Wattiez A.1 1Gynecology Department, IRCAD/EITS, Strasbourg, Bas Rhin, France; 2General Surgery Department, IRCAD/EITS, Strasbourg, Bas Rhin, France Study Objective: To evaluate feasibility and survival for retroperitoneal lymphadenectomy in porcine model. Design: Perform retroperitoneal lymphadenectomy and evaluate feasibility, and survival at three weeks post operatively. Setting: IRCAD / EITS. Patients: Six female pigs weighing 25 to 30 Kg were used in this study according to local laws for animal use. Intervention: Retroperitoneal access is achieved transvaginally with a double channelled gastroscope (Natural Orifice Transluminal Endoscopic Surgery). Three lomboaortic and three pelvic lymph nodes were removed. Operative site is marked with endoscopic clips. Measurements and Main Results: Retroperitoneal pelvic and lomboartic lymphadenectomies were performed successfully in all six pigs with no intra operative complication except one accidental peritoneal perforation in the first pig. In all pigs the operative technique was reproductible. The mean operative time was 5 to 7 min/lymph node dissected, and decreased with experience. Intraoperative complications were: one diffuse anterior abdominal wall emphysema, one parietal bleeding and three pneumoperitoneums. No post operative complications were noted. All animals thrived. On laparoscopic second look there were no abscess, no infection amd no adhesions even in on the accidental peritoneal perforation site. On laparotomy, all animal showed no retroperitoneal abscess, but there was little fibrosis in the lymphadenectomy sites but not along the dissection without lymphadenectomy. Conclusion: Retroperitoneal pelvic and lomboartic lymphadenectomy is still a staging and/or prognostic procedure in many gynecologic and urologic procedures. Associated surgical morbidity range from 2% to 13% of cases. Recent studies show that in selected oncologic cases, there is no difference in survival rates between total lymphadenectomy and removal of macroscopically enlarged lymph nodes (lymph node sampling Retroperitoneal lymphadenectomy by N.O.T.E.S technique is feasible. Exposure and instrumentation must be developed. Further studies are needed to establish its use and indications in humans.
67
Open Communication Session 1dEndoscopic Techniques (3:41 PM d 3:46 PM)
N.O.T.E.S and Gynecology Zacharopoulou C, Nassif J, Wattiez A. Gynecology Department, IRCAD/ EITS, Strasbourg Cedex, Bas Rhin, France Study Objective: To describe retroflexed view of the pelvis in N.O.T.E.S (Natural Orifices Transluminal Surgery) and potential applications in gynecologic field. Design: Inspection of the pelvis in the retroflexed view, during N.O.T.E.S cholecystectomy using the transvaginal access. Setting: IRCAD, University Hospitals of Strasbourg, France. Patients: Six women undergoing transvaginal N.O.T.E.S cholecystectomy for symptomatic cholelythiasis. Exclusion gynacecologic criteria were rectovaginal endometriosis, fixed retroverted uterus and mass in the pounch of Douglas. Intervention: Under general anesthesia, the patients were positioned in steep Trendelemburg. The peritoneal cavity was entered by a a 3 cm posterior colpotomy, 1 cm below the uterine cervix. With the double channel scope in retroflexed position the pelvis was inspected and the accessibility of the pelvic organs such as the uterus and the ovaries, the pouch of Douglas, and utero-vescical pouch explored. The position of
Abstracts / Journal of Minimally Invasive Gynecology 15 (2008) S1eS159
is surgically removed resulting in optimal mass reduction. Hysteroplasty is also much easier because tension free reapproximation is possible. We use mattress for superficial layer reapproximation which make the wound edge inverted. As a result we can prevent adhesion and wound bleeding. The laparoscopic Convex lens resection method is simple, easy to perform and optimal adenomyotic tissue reduction is possible compared to usual adenomyomectomy.
63
Video Session 3dEndometriosis (3:05 AM d 3:13 AM)
The Pelvic Autonomous Nerves: Surgical Anatomy in Radical Laparoscopic Excision of Endometriosis Pereira RMA, Zanatta A, Fonseca J III, Serafini P, de Paula FF, Preti CCL. Pelvic Surgery, Huntington Centro de Medicina Reprodutiva, Sao Paulo, SP, Brazil Deep infiltrating endometriosis treatment requires major retroperitoneal dissection. The pelvic autonomous nerves are at risk of injury because of their close relationship to the deep infiltrating lesions. Morbidity may be great, including bowel and bladder dysfunction. From the period of January 2006 to January 2008, 280 consecutive patients were submitted to laparoscopic radical excision of endometriosis, including bowel resection in 84 cases, at two private health services in Londrina and Sao Paulo, Brazil. Pelvic autonomous nerves isolation was systematically performed, according to the area involved by disease. On this video, we demonstrate the anatomy of the superior hypogastric plexus, the inferior hypogastric nerves, the inferior hypogastric plexus and its three main efferent bundles. We review their visceral function, topography and anatomic relation to pelvic organs and major structures. The objective of the video is to improve knowledge in pelvic neuroanatomy for a proper nerve-sparing surgical technique.
64
Video Session 3dEndometriosis (3:14 AM d 3:19 AM)
Laparoscopic Excision of Endometriotic Bladder Nodule and Repair of Cystotomy Kung RC, Liu G, Lie K. Obstetrics and Gynecology, Women’s College Hospital, Toronto, Ontario, Canada Endometriosis involving the bladder is not common. It may present with cyclic hematuria as well as pelvic pain. This may be palpable vaginally, anterior to the cervix. On cystoscopy, there is mucosal edema and nodularity. Occasionally, it can be misdiagnosed as a malignancy on ultrasound due to its irregular appearance. Laparoscopic excision with simultaneous cystoscopic visualization will minimize the risk of cystotomy. Complete excision is recommended to obtain relief of symptoms. CO2 laser is the preferred modality. Ureteral stents may be necessary if the lesion is in close proximity to the ureteric orifices.
65
Video Session 3dEndometriosis (3:20 AM d 3:27 AM)
Laparoscopic Resection of Rectal Endometriosis Roman H, Tuech JJ, Marpeau L. Gynecology and Obstetrics, University Hospital Rouen, Rouen, France We aim to present our procedure of laparoscopic management of rectal endometriosis. The first stage starts by the dissection of ureters, followed by unilateral section of involved uterosacral ligaments. Pararectal spaces are opened toward lateral limits of the nodule, then dissection of inferior limit is performed until the elevator muscles of the rectum, toward the rectovaginal space under the nodule. The mesorectum is then sectioned. In the second stage, the nodule is sectioned in an anterior and a posterior fragments. The anterior fragment will be removed with the adjacent vagina, and the posterior one with the adjacent rectum. The third stage is performed by the digestive surgeon. The rectum is sectioned using GIA stapler and pulled out through a paraombilical incision. Rectosigmoidal resection is done transparietally. Anastomosis is done laparoscopically
using transanal stapling device PCEA. The omentoplasty and ileostomy are done to prevent rectovaginal fistulae. Ileostomy is closed 2 months later.
66
Open Communication Session 1dEndoscopic Techniques (3:35 PM d 3:40 PM)
Retroperitoneal Lymphadenectomy by N.O.T.E.S Technique in Porcine Model: Feasibility and Survival Study Nassif J,1 Zacharopoulou C,1 Perretta S,2 Dallemagne B,2 Marescaux J,2 Wattiez A.1 1Gynecology Department, IRCAD/EITS, Strasbourg, Bas Rhin, France; 2General Surgery Department, IRCAD/EITS, Strasbourg, Bas Rhin, France Study Objective: To evaluate feasibility and survival for retroperitoneal lymphadenectomy in porcine model. Design: Perform retroperitoneal lymphadenectomy and evaluate feasibility, and survival at three weeks post operatively. Setting: IRCAD / EITS. Patients: Six female pigs weighing 25 to 30 Kg were used in this study according to local laws for animal use. Intervention: Retroperitoneal access is achieved transvaginally with a double channelled gastroscope (Natural Orifice Transluminal Endoscopic Surgery). Three lomboaortic and three pelvic lymph nodes were removed. Operative site is marked with endoscopic clips. Measurements and Main Results: Retroperitoneal pelvic and lomboartic lymphadenectomies were performed successfully in all six pigs with no intra operative complication except one accidental peritoneal perforation in the first pig. In all pigs the operative technique was reproductible. The mean operative time was 5 to 7 min/lymph node dissected, and decreased with experience. Intraoperative complications were: one diffuse anterior abdominal wall emphysema, one parietal bleeding and three pneumoperitoneums. No post operative complications were noted. All animals thrived. On laparoscopic second look there were no abscess, no infection amd no adhesions even in on the accidental peritoneal perforation site. On laparotomy, all animal showed no retroperitoneal abscess, but there was little fibrosis in the lymphadenectomy sites but not along the dissection without lymphadenectomy. Conclusion: Retroperitoneal pelvic and lomboartic lymphadenectomy is still a staging and/or prognostic procedure in many gynecologic and urologic procedures. Associated surgical morbidity range from 2% to 13% of cases. Recent studies show that in selected oncologic cases, there is no difference in survival rates between total lymphadenectomy and removal of macroscopically enlarged lymph nodes (lymph node sampling Retroperitoneal lymphadenectomy by N.O.T.E.S technique is feasible. Exposure and instrumentation must be developed. Further studies are needed to establish its use and indications in humans.
67
Open Communication Session 1dEndoscopic Techniques (3:41 PM d 3:46 PM)
N.O.T.E.S and Gynecology Zacharopoulou C, Nassif J, Wattiez A. Gynecology Department, IRCAD/ EITS, Strasbourg Cedex, Bas Rhin, France Study Objective: To describe retroflexed view of the pelvis in N.O.T.E.S (Natural Orifices Transluminal Surgery) and potential applications in gynecologic field. Design: Inspection of the pelvis in the retroflexed view, during N.O.T.E.S cholecystectomy using the transvaginal access. Setting: IRCAD, University Hospitals of Strasbourg, France. Patients: Six women undergoing transvaginal N.O.T.E.S cholecystectomy for symptomatic cholelythiasis. Exclusion gynacecologic criteria were rectovaginal endometriosis, fixed retroverted uterus and mass in the pounch of Douglas. Intervention: Under general anesthesia, the patients were positioned in steep Trendelemburg. The peritoneal cavity was entered by a a 3 cm posterior colpotomy, 1 cm below the uterine cervix. With the double channel scope in retroflexed position the pelvis was inspected and the accessibility of the pelvic organs such as the uterus and the ovaries, the pouch of Douglas, and utero-vescical pouch explored. The position of