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Robotic Pelvic Lymphadenectomy in Pregnancy
S116
Abstracts / Journal of Minimally Invasive Gynecology 22 (2015) S1–S253
297 Laparoscopic Para-Aortic Lymphadenectomy (LPAL): Standard Surgical Boundary and Technique Choi JS,1 Bae J,1 Lee WM,1 Koh AR,1 Jung US,2 Ko JH.3 1 Obstetrics and Gynecology, Hanyang University College of Medicine, Seoul, Republic of Korea; 2Obstetrics and Gynecology, Hallym University Hangang Sacred Heart Hospital, Seoul, Republic of Korea; 3Obstetrics and Gynecology, Kangwon National University Hospital, Chuncheon, Republic of Korea Our surgical technique are as follows:Firstly, the 10mm telescope was turned clockwise from the usual view for the LPAL. The peritoneum was dissected along the aorta, up to the IMA level. After completing the right lower part lymphadenectomy, we proceeded to the left lower para-aortic lymphadenectomy. The dissection was done in a step-wise fashion, leaving enough safety margin between the surgical field and the ureter. After successfully identifying the left ureter, left paraaortic lymph node dissection was resumed, which was performed with the powerblade and the ultrasonic device. Afterward, the dissection was extended upward until we reached the right renal artery. Once we finished the dissection around the right renal artery, we continued to perform the procedure on the left side. We began the dissection from the IMA level and continued upward until we reached the left renal vein.
298 Total Laparoscopic Nerve Sparing Radical Hysterectomy for Cervical Cancer and Retossigmoidectomy for Deep Intestinal Endometriosis in a Patient With Uterus Didelphys Ribeiro R,1 Kondo W,2 M.A. Luz,1 Hayashi RM,2 Kondo MTZ.2 1Surgical Oncology, Erasto Gaertner Hospital, Curitiba, Parana, Brazil; 2 Ginecology, Sugisawa Hospital, Curitiba, Parana, Brazil Uterus didelphys is estimated to occur in 0.1–0.5% of American women. The combination of cervical cancer with deep intestinal endometriosis in a patient with this uterine malformation has never been described. For patients with initial cervical cancer radical hysterectomy is a good option. Deep rectal endometriosis frequently demands intestinal resection and it’s associated with pelvic splanchnic nerves infiltration by endometriosis. Both procedures have a high rate of urinary complications. Nerve sparing radical hysterectomy has emerged as a technical modification to lower bladder dysfunction and the same principles can be used in deep infiltrating endometriosis. Surgical time was 190 min, 80ml blood loss and no transoperatory complications. The patient was discharged on the 3th postoperative day. She had short term urinary retention that was resolved with intermittent selfcatheterisation for 3 weeks. Pathological analysis confirmed an epidermoid carcinoma, with 20mm stromal infiltration and 2 positive lymph nodes out of 21.
299 Robotic Pelvic Lymphadenectomy in Pregnancy Mathews SS, Nagarsheth NP. Icahn School of Medicine at Mount Sinai, New York, New York
Our video submission demonstrates the technique, safety, effectiveness of robotic pelvic lymphadenectomy in pregnancy to help guide treatment in stage 1B1 squamous cell carcinoma of the cervix. We emphasize the importance of proper port placement to increase visualization and access to the pelvic side walls and eliminate risk to the gravid uterus. Careful dissection using specific robotic techniques allow for safe and effective lymph node sampling. A multidisciplinary approach to patient counseling and treatment plan formulation is necessary in this case. This minimally invasive approach gave the patient an opportunity to maintain her pregnancy despite a concerning diagnosis.
300 Laparoscopic Debulking Pelvic Lymphadenectomy in Cervical Cancer Cintra GF, Tsunoda AT, Simioni EB, Reis RD, Affonso R, Simonsen M, Andrade CECM. Gynecology Oncology, Barretos Cancer Hospital, Barretos, SP, Brazil Lymph node involvement is one of the most important prognostic factors in cervical cancer. Although new developments in radiotherapy have improved the outcomes of these patients, there are still therapeutic limitations for bulky nodes, especially when IMRT is not available. Pre-treatment lymph node dissection for staging purposes in locally advanced cervical cancer has been widely performed and could improve survival when unsuspected para-aortic metastasis is diagnosed. We present a surgical video of a videolaparoscopic lymphadenectomy in a patient with IIB SCC of the cervix with enlarged bulky pelvic nodes. A systematic approach with establishment the retroperitoneal spaces and identification of the anatomic landmarks (genitofemural nerve, external and internal iliac artery/ vein, ureters, obturatory nerve and obliterated umbilical artery) was crucial in the feasibility of the complex procedure, which had a higher technical difficulty due to the extra-capsular spread and firm adhesions to the main vessels.
301 Making Clear of the Structure of Vesicouterine Ligament for Laparoscopic Radical Hysterectomy Shiki Y. Obstetrics and Gynecology, Osaka Rosai Hospital, Sakai, Osaka, Japan Management of vesicouterine ligament is the key procedure of laparoscopic radical hysterectomy. Venous return from bladder is not parallel to artery. Unexpected hemorrhage can occur during the procedure due to the blackbox nature of vesicouterine ligament, and in case of injury to vesicouterine ligament, thermal damage for hemostasis may lead to urinary dysfunction. Reduction of urinary complication is expected by detailed understanding of the structure of vesicouterine ligament. Cervicovesical vessel is the component of anterior vesicouterine ligament. Vesical veins and vesical nerve branch are the component of posterior layer of vesicouterine ligament, as clearly shown in the video. Knowledge of the construction of vesicouterine ligament also help us to transect vesical veins while keeping the identified vesical nerve branch, that is essential for saving voiding function while maintaining the radicality of hysterectomy.
Abstracts / Journal of Minimally Invasive Gynecology 22 (2015) S1–S253
297 Laparoscopic Para-Aortic Lymphadenectomy (LPAL): Standard Surgical Boundary and Technique Choi JS,1 Bae J,1 Lee WM,1 Koh AR,1 Jung US,2 Ko JH.3 1 Obstetrics and Gynecology, Hanyang University College of Medicine, Seoul, Republic of Korea; 2Obstetrics and Gynecology, Hallym University Hangang Sacred Heart Hospital, Seoul, Republic of Korea; 3Obstetrics and Gynecology, Kangwon National University Hospital, Chuncheon, Republic of Korea Our surgical technique are as follows:Firstly, the 10mm telescope was turned clockwise from the usual view for the LPAL. The peritoneum was dissected along the aorta, up to the IMA level. After completing the right lower part lymphadenectomy, we proceeded to the left lower para-aortic lymphadenectomy. The dissection was done in a step-wise fashion, leaving enough safety margin between the surgical field and the ureter. After successfully identifying the left ureter, left paraaortic lymph node dissection was resumed, which was performed with the powerblade and the ultrasonic device. Afterward, the dissection was extended upward until we reached the right renal artery. Once we finished the dissection around the right renal artery, we continued to perform the procedure on the left side. We began the dissection from the IMA level and continued upward until we reached the left renal vein.
298 Total Laparoscopic Nerve Sparing Radical Hysterectomy for Cervical Cancer and Retossigmoidectomy for Deep Intestinal Endometriosis in a Patient With Uterus Didelphys Ribeiro R,1 Kondo W,2 M.A. Luz,1 Hayashi RM,2 Kondo MTZ.2 1Surgical Oncology, Erasto Gaertner Hospital, Curitiba, Parana, Brazil; 2 Ginecology, Sugisawa Hospital, Curitiba, Parana, Brazil Uterus didelphys is estimated to occur in 0.1–0.5% of American women. The combination of cervical cancer with deep intestinal endometriosis in a patient with this uterine malformation has never been described. For patients with initial cervical cancer radical hysterectomy is a good option. Deep rectal endometriosis frequently demands intestinal resection and it’s associated with pelvic splanchnic nerves infiltration by endometriosis. Both procedures have a high rate of urinary complications. Nerve sparing radical hysterectomy has emerged as a technical modification to lower bladder dysfunction and the same principles can be used in deep infiltrating endometriosis. Surgical time was 190 min, 80ml blood loss and no transoperatory complications. The patient was discharged on the 3th postoperative day. She had short term urinary retention that was resolved with intermittent selfcatheterisation for 3 weeks. Pathological analysis confirmed an epidermoid carcinoma, with 20mm stromal infiltration and 2 positive lymph nodes out of 21.
299 Robotic Pelvic Lymphadenectomy in Pregnancy Mathews SS, Nagarsheth NP. Icahn School of Medicine at Mount Sinai, New York, New York
Our video submission demonstrates the technique, safety, effectiveness of robotic pelvic lymphadenectomy in pregnancy to help guide treatment in stage 1B1 squamous cell carcinoma of the cervix. We emphasize the importance of proper port placement to increase visualization and access to the pelvic side walls and eliminate risk to the gravid uterus. Careful dissection using specific robotic techniques allow for safe and effective lymph node sampling. A multidisciplinary approach to patient counseling and treatment plan formulation is necessary in this case. This minimally invasive approach gave the patient an opportunity to maintain her pregnancy despite a concerning diagnosis.
300 Laparoscopic Debulking Pelvic Lymphadenectomy in Cervical Cancer Cintra GF, Tsunoda AT, Simioni EB, Reis RD, Affonso R, Simonsen M, Andrade CECM. Gynecology Oncology, Barretos Cancer Hospital, Barretos, SP, Brazil Lymph node involvement is one of the most important prognostic factors in cervical cancer. Although new developments in radiotherapy have improved the outcomes of these patients, there are still therapeutic limitations for bulky nodes, especially when IMRT is not available. Pre-treatment lymph node dissection for staging purposes in locally advanced cervical cancer has been widely performed and could improve survival when unsuspected para-aortic metastasis is diagnosed. We present a surgical video of a videolaparoscopic lymphadenectomy in a patient with IIB SCC of the cervix with enlarged bulky pelvic nodes. A systematic approach with establishment the retroperitoneal spaces and identification of the anatomic landmarks (genitofemural nerve, external and internal iliac artery/ vein, ureters, obturatory nerve and obliterated umbilical artery) was crucial in the feasibility of the complex procedure, which had a higher technical difficulty due to the extra-capsular spread and firm adhesions to the main vessels.
301 Making Clear of the Structure of Vesicouterine Ligament for Laparoscopic Radical Hysterectomy Shiki Y. Obstetrics and Gynecology, Osaka Rosai Hospital, Sakai, Osaka, Japan Management of vesicouterine ligament is the key procedure of laparoscopic radical hysterectomy. Venous return from bladder is not parallel to artery. Unexpected hemorrhage can occur during the procedure due to the blackbox nature of vesicouterine ligament, and in case of injury to vesicouterine ligament, thermal damage for hemostasis may lead to urinary dysfunction. Reduction of urinary complication is expected by detailed understanding of the structure of vesicouterine ligament. Cervicovesical vessel is the component of anterior vesicouterine ligament. Vesical veins and vesical nerve branch are the component of posterior layer of vesicouterine ligament, as clearly shown in the video. Knowledge of the construction of vesicouterine ligament also help us to transect vesical veins while keeping the identified vesical nerve branch, that is essential for saving voiding function while maintaining the radicality of hysterectomy.