- Email: [email protected]
189: Adhesion Reformation after Laparoscopic Adhesiolysis: Where, When, and What Type are Most Likely to Recur?
Oral Presentations or potential malignancies (1 of 1 hyperplasia) would have been diagnosed. Conclusion: As far as our study shows, it is not clear that asymptomatic women under tamoxifen for breast cancer should undergo an invasive technique as hysteroscopy is. However, hysteroscopy is mandatory when a women treated with tamoxifen begins with metrorrhagia. 187 Ovarioscopy and Laparoscopic Removal of a Giant Ovarian Cyst 1 Love, BR, 2G Murray. 1Canton, Mississippi; 2Madison County Medical Center, Canton, Mississippi Study Objective: The objective of these techniques was to avoid a laparotomy in a patient with a giant ovarian cyst that was greater than 30cms. Design: One case presentation. Setting: Outpatient OR Madison County Medical Center. Patient: This patient was a 21 y/o single nulliparous black female who presented toe the general surgeon with severe abdominal pain and increasing abdominal girth. She had an MRI that demostrated a cystic mass in the abdomen of greater than 30 cms without ascites. Her CEA AND C125 WERE WITHIN normal limits. Intervention: We elected to perform her case with the dual use of ovarioscopy and laparoscopy. Under general anesthesia we proceded with her treatment. First, we inserted 2 five mm trocars directedly into the giant ovarian cyst. One port was used for a visual port and the other port was used with the 5 mm suction irrigater to remove 2800 ccs of clear fluid from the mass. Subsequently, we used the “hairpin rolling” technique to roll the cyst onto a laparoscopic grasper. Then, we resected the flattened ovarian cyst from the right ovary. We used a 10 mm port to remove the mass from the abdomen. After gas was allowed to escape from the abdomen, we closed our three ports. The pt was discharged from the hospital the next day. Her post op recovery was uneventful. Measurements and Main Results: Cytology from the cyst showed no cells. The pathology from the cyst wall was bening with ciliated cells. Conclusion: We believe that even large cystic, non-malignant ovarian cyst can be removed with MIS using the combined ovarioscopic and laparoscopic technique. 188 Safety, Feasibility, and Costs of Outpatient Laparoscopic Extraperitoneal Aortic Nodal Dissection for Locally Advanced Cervical Carcinoma 1 Lowe MP, 2Tillmanns TT. 1Chicago, Illinois; 2The West Clinic/The University of Tennessee, Memphis, Tennessee Study Objective: To report on the safety, feasibility, and costs of outpatient laparoscopic extraperitoneal aortic
S69 lymph node dissection (LEPSS) for locally advanced cervical carcinoma. Design: Retrospective analysis. Setting: Academic affiliated gynecologic oncology group practice in the Midsouth. Patients: Eighteen patients with clinical stage IIB-IVA cervical carcinoma with no evidence of bulky aortic lymphadenopathy (⬎1.0 cm) on pre-operative computed tomography. Records were reviewed for demographics, operative findings, complications, length of stay, and CT scan aortic nodal status. As a comparison, the average costs for outpatient LEPSS and outpatient CT, MRI and PET scan at our institution were calculated. Intervention: Outpatient laparoscopic extraperitoneal aortic lymph node dissection. Measurements and Main Results: Eighteen outpatient LEPSS procedures were performed. Median age was 49 (22-72). Median BMI was 29 (18-51) Median operative time was 108 minutes (60-135 min). Median aortic nodal count was 10 (5-20 nodes). Median blood loss was 25 cc (10-50 cc). There were no intraoperative complications. No patient required overnight hospitalization. One patient experienced a lymphocyst postoperatively. There was no delay in the initiation of chemoradiation for any of the patients with a median onset of 10 days from the date of surgery. Occult aortic nodal metastasis was detected in 11% of the patients with a negative pre-operative CT scan. The average calculated costs at our institution for outpatient LEPSS was $5,233 dollars versus $1,520 dollars for CT scan, $4,830 dollars for MRI and $5,494 dollars for a PET scan. Conclusion: To our knowledge this is the first reported experience of outpatient laparoscopic extraperitoneal aortic lymph node dissection for locally advanced cervical cancer. Outpatient LEPSS appears to be a safe and feasible procedure in the hands of an experienced surgeon, however further study is warranted. From a cost analysis perspective, outpatient LEPSS appears equivalent to PET scan and MRI, but is more expensive that CT scan. 189 Adhesion Reformation after Laparoscopic Adhesiolysis: Where, When, and What Type are Most Likely to Recur? Luciano DE, Luciano AA. Center for Fertility and Women’s Health, New Britain, Connecticutt Study Objective: Do the severity or extent of adhesions, the organs involved or the presence of endometriosis predict recurrence or de novo adhesions formation? Design: Compare adhesion scores at initial operative laparoscopy and at second-look laparoscopy utilizing the rAFS adhesion classification system. Setting: University affiliated REI center. Patients: Thirty-eight women with moderate to severe adhesions who underwent laparoscopic adhesiolysis and second look laparoscopy at a university affiliated REI center.
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Intervention: Adhesion scores were assessed at 6 sites in the peritoneal cavity prior to the initial laparoscopic adhesiolysis and compared to the adhesion scores at second look laparoscopy. Adhesions were evaluated by extent, severity, organ involvement, and presence or absence of endometriosis to evaluate potential determinants of recurrence and de novo adhesion formation. All adhesions were totally removed at initial laparoscopy, all patients received 1000 cc of Lactated Ringers at the end of the procedures and the same surgeon treated all patients. Measurements and Main Results: Adhesion scores decreased in extent [23.3% (p⫽0,005)] and severity [26.3% (p⫽0.001)]. Dense adhesions decreased 31% (p⫽0.00). filmy 35% (p⫽0.048). Extent of adhesions assessed at ⬍1/3, 1/3-2/3, and ⬎2/3 decreased by 33% (p⫽0.002), 42% (p⫽0.00), and 21% (p⫽0.00), respectively. Severity and extent of adhesions of the abdominal wall decreased by 45% (p⫽0.003) and 40% (p⫽0.016); of the bowel by 33% (p⫽0.002) and 31% (p⫽0.012); and of the posterior cul de sac by 14% (p⫽0.040) and 9.5% (p⫽0.091). The severity and extent of adhesions involving both adnexa decreased by 12%-15%, which was not statistically significant. The presence of endometriosis did not affect adhesion recurrence. De novo adhesions developed at 48 of 228 potential sites (21%) occurring in 22 of the 38 patients, and were most frequent and severe on the adnexa and least on the abdominal wall. Conclusion: Both extent and severity of adhesions are significantly reduced by laparoscopic adhesiolysis. The initial extent and severity of adhesions did not predict recurrence, however the involved organ did, being most frequent on the adnexa and least frequent on the abdominal wall and bowel. 190 Cornual Pregnancy Successfully Treated by Transcervical Suction and Operative Hysteroscopy After Failing Methotrexate Treatment Luk J. Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts Study Objective: When the cornual ectopic pregnancy failed methotrexate treatment, it is usually managed surgically which affects future fertility. Transcervical suction and hysteroscopic resection under sonographic guidance of the cornual ectopic pregnancy is a possible conservative management. Design: Case Report. Intervention: Transcervical suction and hysteroscopic resection of the cornual ectopic pregnancy after failing methotrexate treatment. Measurements and Main Results: Twenty-eight y/o G1P0 at 5 and 6/7 wks first presented with intermittent vaginal spotting and abdominal cramping over the 2 weeks prior to presentation. Beta human choronic was shows to be 8557. U/S showed that an abnormal appearing sace was located in the right peripheral endometrium mesasuring 3 by 9 by 8
mm, yolk sac was present but without fetal pole. Pt was then given intramuscular methotrexate but 7 days later, patient’s beta HCG was continued to rise up to 17976 and on ultrasound the cornual cystic component has increased in size, measuring 1.7cm on all sides. Pt was then brought to the operating room. A large hyperemic mass was located at the right cornua, directly visualized with the diagnostic hysterscopy. Then a 7mm straight suction cannula was then advance to the fundus under sonographic guidance. Once the gestational sac was no longer visualized on ultrasound, the hysteroscope with a polyp forcep was used to resect the rest of the residual implantation site. 20 days later, patient’s HCG was dropped to zero and patient endometrial cavity was intact without any perforation with the confirmation of a HSG. Conclusion: Transcervical suction and hysteroscopic resection may be an alternative surgical intervention for a cornual ectopic pregnancy that failed methotrexate treatment. 191 A Prospective, Randomized, Double-blind, Placebocontrolled Trial of Multimodal Intra-operative Analgesia for Laparoscopic Excision of Endometriosis Lyons SD, Wilson S. Royal Hospital for Women, Randwick, Sydney, Australia Study Objective: To assess the efficacy of multimodal intraoperative analgesia in reducing post-operative pain and/or opioid requirements in women undergoing laparoscopic excision of endometriosis. Design: A prospective, randomised, double-blind, placebocontrolled trial (Canadian Task Force classification I). Setting: A tertiary referral hospital. Patients: Random assignment of 66 women undergoing laparoscopic excision of endometriosis to receive intra-operative multimodal analgesia (30 patients) or placebo (36 patients). Intervention: Analgesia consisted of Diclofenac sodium 100 mg suppository per rectum and 0.75% Ropivacaine to portal sites, sub-peritoneally under excision sites and topically to each sub-diaphragmatic area. Post-operative inhospital analgesia was standardized for all patients and included IV morphine delivered by patient controlled analgesia (PCA) in the ward. Measurements and Main Results: The primary outcome measures were [1] postoperative opioid analgesic requirements and [2] postoperative pain intensity measured by Visual Analogue Scale (VAS) and Verbal Descriptor Scale (VDS). There was no difference in baseline variables between the two groups. The analgesic group used significantly less morphine in recovery (0.0 V 8.0 mg; p ⫽ 0.016), PCA morphine in the ward (9.0 V 21.5 mg; p⫽0.05), and total hospital opioid (recovery morphine, PCA morphine and ward breakthrough opioid) (19.0 V 34.5 mg; p ⫽ 0.017) compared to the placebo group. Results are presented as
S69 lymph node dissection (LEPSS) for locally advanced cervical carcinoma. Design: Retrospective analysis. Setting: Academic affiliated gynecologic oncology group practice in the Midsouth. Patients: Eighteen patients with clinical stage IIB-IVA cervical carcinoma with no evidence of bulky aortic lymphadenopathy (⬎1.0 cm) on pre-operative computed tomography. Records were reviewed for demographics, operative findings, complications, length of stay, and CT scan aortic nodal status. As a comparison, the average costs for outpatient LEPSS and outpatient CT, MRI and PET scan at our institution were calculated. Intervention: Outpatient laparoscopic extraperitoneal aortic lymph node dissection. Measurements and Main Results: Eighteen outpatient LEPSS procedures were performed. Median age was 49 (22-72). Median BMI was 29 (18-51) Median operative time was 108 minutes (60-135 min). Median aortic nodal count was 10 (5-20 nodes). Median blood loss was 25 cc (10-50 cc). There were no intraoperative complications. No patient required overnight hospitalization. One patient experienced a lymphocyst postoperatively. There was no delay in the initiation of chemoradiation for any of the patients with a median onset of 10 days from the date of surgery. Occult aortic nodal metastasis was detected in 11% of the patients with a negative pre-operative CT scan. The average calculated costs at our institution for outpatient LEPSS was $5,233 dollars versus $1,520 dollars for CT scan, $4,830 dollars for MRI and $5,494 dollars for a PET scan. Conclusion: To our knowledge this is the first reported experience of outpatient laparoscopic extraperitoneal aortic lymph node dissection for locally advanced cervical cancer. Outpatient LEPSS appears to be a safe and feasible procedure in the hands of an experienced surgeon, however further study is warranted. From a cost analysis perspective, outpatient LEPSS appears equivalent to PET scan and MRI, but is more expensive that CT scan. 189 Adhesion Reformation after Laparoscopic Adhesiolysis: Where, When, and What Type are Most Likely to Recur? Luciano DE, Luciano AA. Center for Fertility and Women’s Health, New Britain, Connecticutt Study Objective: Do the severity or extent of adhesions, the organs involved or the presence of endometriosis predict recurrence or de novo adhesions formation? Design: Compare adhesion scores at initial operative laparoscopy and at second-look laparoscopy utilizing the rAFS adhesion classification system. Setting: University affiliated REI center. Patients: Thirty-eight women with moderate to severe adhesions who underwent laparoscopic adhesiolysis and second look laparoscopy at a university affiliated REI center.
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Journal of Minimally Invasive Gynecology, Vol 14, No 6, November/December Supplement 2007
Intervention: Adhesion scores were assessed at 6 sites in the peritoneal cavity prior to the initial laparoscopic adhesiolysis and compared to the adhesion scores at second look laparoscopy. Adhesions were evaluated by extent, severity, organ involvement, and presence or absence of endometriosis to evaluate potential determinants of recurrence and de novo adhesion formation. All adhesions were totally removed at initial laparoscopy, all patients received 1000 cc of Lactated Ringers at the end of the procedures and the same surgeon treated all patients. Measurements and Main Results: Adhesion scores decreased in extent [23.3% (p⫽0,005)] and severity [26.3% (p⫽0.001)]. Dense adhesions decreased 31% (p⫽0.00). filmy 35% (p⫽0.048). Extent of adhesions assessed at ⬍1/3, 1/3-2/3, and ⬎2/3 decreased by 33% (p⫽0.002), 42% (p⫽0.00), and 21% (p⫽0.00), respectively. Severity and extent of adhesions of the abdominal wall decreased by 45% (p⫽0.003) and 40% (p⫽0.016); of the bowel by 33% (p⫽0.002) and 31% (p⫽0.012); and of the posterior cul de sac by 14% (p⫽0.040) and 9.5% (p⫽0.091). The severity and extent of adhesions involving both adnexa decreased by 12%-15%, which was not statistically significant. The presence of endometriosis did not affect adhesion recurrence. De novo adhesions developed at 48 of 228 potential sites (21%) occurring in 22 of the 38 patients, and were most frequent and severe on the adnexa and least on the abdominal wall. Conclusion: Both extent and severity of adhesions are significantly reduced by laparoscopic adhesiolysis. The initial extent and severity of adhesions did not predict recurrence, however the involved organ did, being most frequent on the adnexa and least frequent on the abdominal wall and bowel. 190 Cornual Pregnancy Successfully Treated by Transcervical Suction and Operative Hysteroscopy After Failing Methotrexate Treatment Luk J. Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts Study Objective: When the cornual ectopic pregnancy failed methotrexate treatment, it is usually managed surgically which affects future fertility. Transcervical suction and hysteroscopic resection under sonographic guidance of the cornual ectopic pregnancy is a possible conservative management. Design: Case Report. Intervention: Transcervical suction and hysteroscopic resection of the cornual ectopic pregnancy after failing methotrexate treatment. Measurements and Main Results: Twenty-eight y/o G1P0 at 5 and 6/7 wks first presented with intermittent vaginal spotting and abdominal cramping over the 2 weeks prior to presentation. Beta human choronic was shows to be 8557. U/S showed that an abnormal appearing sace was located in the right peripheral endometrium mesasuring 3 by 9 by 8
mm, yolk sac was present but without fetal pole. Pt was then given intramuscular methotrexate but 7 days later, patient’s beta HCG was continued to rise up to 17976 and on ultrasound the cornual cystic component has increased in size, measuring 1.7cm on all sides. Pt was then brought to the operating room. A large hyperemic mass was located at the right cornua, directly visualized with the diagnostic hysterscopy. Then a 7mm straight suction cannula was then advance to the fundus under sonographic guidance. Once the gestational sac was no longer visualized on ultrasound, the hysteroscope with a polyp forcep was used to resect the rest of the residual implantation site. 20 days later, patient’s HCG was dropped to zero and patient endometrial cavity was intact without any perforation with the confirmation of a HSG. Conclusion: Transcervical suction and hysteroscopic resection may be an alternative surgical intervention for a cornual ectopic pregnancy that failed methotrexate treatment. 191 A Prospective, Randomized, Double-blind, Placebocontrolled Trial of Multimodal Intra-operative Analgesia for Laparoscopic Excision of Endometriosis Lyons SD, Wilson S. Royal Hospital for Women, Randwick, Sydney, Australia Study Objective: To assess the efficacy of multimodal intraoperative analgesia in reducing post-operative pain and/or opioid requirements in women undergoing laparoscopic excision of endometriosis. Design: A prospective, randomised, double-blind, placebocontrolled trial (Canadian Task Force classification I). Setting: A tertiary referral hospital. Patients: Random assignment of 66 women undergoing laparoscopic excision of endometriosis to receive intra-operative multimodal analgesia (30 patients) or placebo (36 patients). Intervention: Analgesia consisted of Diclofenac sodium 100 mg suppository per rectum and 0.75% Ropivacaine to portal sites, sub-peritoneally under excision sites and topically to each sub-diaphragmatic area. Post-operative inhospital analgesia was standardized for all patients and included IV morphine delivered by patient controlled analgesia (PCA) in the ward. Measurements and Main Results: The primary outcome measures were [1] postoperative opioid analgesic requirements and [2] postoperative pain intensity measured by Visual Analogue Scale (VAS) and Verbal Descriptor Scale (VDS). There was no difference in baseline variables between the two groups. The analgesic group used significantly less morphine in recovery (0.0 V 8.0 mg; p ⫽ 0.016), PCA morphine in the ward (9.0 V 21.5 mg; p⫽0.05), and total hospital opioid (recovery morphine, PCA morphine and ward breakthrough opioid) (19.0 V 34.5 mg; p ⫽ 0.017) compared to the placebo group. Results are presented as