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ABSTRACT: We report the laparoscopic formation of a colon neovagina following radical hysterectomy with subtotal colpectomy and radiotherapy in a 43-year-old woman who wished to resume normal vaginal sexual intercourse. The rectum was transected by a laparoscopic stapling device, preserving the inferior mesenteric and the superior rectal artery. By suprapubic mini-laparotomy, the rectosigmoid colon was eventerated and transected 8 cm above the staple line. Following colorectal anastomosis, the isolated bowel segment was rotated 180 degrees and placed on the right side of the anastomosis. A 12-mm trocar was introduced, transvaginally, and the isolated bowel segment was sutured to the vaginal resection margin. There were no peri- or postoperative complications. Six months after surgery, a stenotic area at the entrance to the neovagina was incised. At 12 months after primary surgery, the neovagina allowed normal sexual activity. Laparoscopically assisted formation of a colon neovagina is a surgical alternative for vaginal reconstruction that can be performed successfully even in irradiated patients.
Surgical Endoscopy 07/2001; 15(6):623. · 4.01 Impact Factor
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ABSTRACT: To decrease postoperative morbidity associated with radical hysterectomy Rutledge type III, we identified the parasympathetic innervation of the bladder in the cardinal ligament.
During laparoscopic dissection of the cardinal ligament, we used 7x magnification on 38 consecutive patients with cervical cancer stages IB1 to IIIA with high risk for parametrial involvement when we performed laparoscopy-assisted radical vaginal hysterectomy type III between August 1997 and January 1999.
The middle rectal artery was identified as a landmark separating the vascular from the neural part of the cardinal ligament. The neural part was shown to contain the splanchnic pelvic nerves which anastomose with the pelvic plexus. Following preservation of these neural structures all patients were able to void their bladder spontaneously. Following nerve-sparing technique, patients regained bladder function significantly quicker compared with a control group (n = 28) in which the neural part of the cardinal ligament had not been preserved: suprapubic drainage 11.2 days versus 21.4 days (P = 0.0007).
Using the middle rectal artery as a landmark the neural part of the cardinal ligament can be preserved, resulting in preservation of the motor function of the bladder.
Gynecologic Oncology 12/2000; 79(2):154-7. · 3.89 Impact Factor
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ABSTRACT: We wanted to establish a technique of laparoscopically assisted radical vaginal surgery for deep endometriosis of the rectovaginal septum with extensive rectal involvement.
The procedure is started by vaginally excising the involved area which is left on the rectum, followed by bilateral dissection of the pararectal and retrorectal spaces. Para- and retrosigmoido-rectal spaces are developed laparoscopically along the coccygeosacral bone and medially to the pelvic splanchnic nerves toward the para- and retrorectal openings that were made transvaginally. Rectal transection is done with a laparoscopic stapling device caudal to the endometriotic lesion. Using a suprapubic minilaparotomy, the bowel is transected cranial to the lesion and reintroduced into the abdomen, and a transanal circular stapler anastomosis is done.
Thirty-four women had this procedure. The mean distance of the anastomosis was 4 cm above the anus. None required ileostomy or colostomy and no major complications were noted.
The combination of laparoscopic and vaginal approaches is useful for removing extensive endometriotic infiltration of the rectosigmoid; bladder and rectal function and fertility can be preserved.
Obstetrics and Gynecology 09/2000; 96(2):304-7. · 4.73 Impact Factor
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ABSTRACT: To assess the number of operations necessary to develop and standardize a laparoscopic approach to pelvic and para-aortic lymphadenectomy, with radicality and number of complications as quality markers.
Over 4 years, 108 women had complete laparoscopic pelvic and para-aortic lymphadenectomies combined with laparoscopy-assisted radical vaginal hysterectomies for primary therapy of cervical cancer. Complete data and videotapes were available for 99 women. Operating time and radicality for specific anatomic subareas were measured by review of video documentation and histologic lymph node counts. Intra- and postoperative complications were recorded prospectively. To analyze the progress of surgery, we compared two groups of women, one operated on at the beginning of our study (early group, subjects 6-35) and one operated on in the final period of the study (late group, subjects 79-108).
The operating time for pelvic and para-aortic lymphadenectomy increased constantly. Comparing the early and late groups for para-aortic lymphadenectomy, there was an increase in mean operating time (34.8 versus 73.2 minutes; P < .001) and mean histologic lymph node yield (5.1 versus 10.6; P < .001). For pelvic lymphadenectomy, mean operating time increased slightly (60.7 versus 69.7 minutes; not significant) but mean histologic lymph node count decreased over time (24.3 versus 21.0; not significant). Retrospective evaluation of videotapes showed that the radicality of lymphadenectomy improved continuously in all evaluated subareas.
Establishment of a protocol for para-aortic and pelvic lymphadenectomy took 100 operations. Video documentation was a more reliable indicator of progress in technical performance than were histologic lymph node counts.
Obstetrics and Gynecology 03/2000; 95(3):348-52. · 4.73 Impact Factor
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ABSTRACT: We evaluated the anatomy of the infrarenal portion of the human inferior vena cava and their ventral tributaries by video laparoscopy.
A total of 112 patients underwent laparoscopic para-aortic lymphadenectomy for gynecologic malignancies. All procedures were videotaped. The number and anatomic distribution of the infrarenal tributaries of the anterior part of the inferior vena cava was evaluated retrospectively from videotapes. The inferior vena cava was divided into 3 levels: the area of the bifurcation of the vena cava (level 1), the area between the bifurcation and the inferior mesenteric artery (level 2), and the area between the inferior mesenteric artery and the right ovarian vein (level 3).
Tributaries were found in level 1 in 65 (58%) patients, in level 2 in 22 (19.6%) patients, and in level 3 in 1 (0.9%) patient; in 24 (21.5%) patients no tributaries were found. A total of 237 tributaries was counted: 82.3% (195 of 237) were located at level 1, 17.3% (41 of 237) at level 2, and 0.4% (1 of 237) at level 3. Patients with tributaries had a mean of 3 tributaries in level 1, a mean of 1.7 tributaries in level 2, and 1 patient had 1 tributary in level 3.
The ventral tributaries of the inferior vena cava show a specific distribution pattern. The knowledge of these anatomic landmarks can be important for laparoscopic surgeons to avoid accidental injury.
American Journal of Obstetrics and Gynecology 12/1998; 179(5):1295-7. · 3.47 Impact Factor
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ABSTRACT: The clinical usefulness of laparoscopic pelvic and para-aortic lymphadenectomy for staging and therapy of gynecological cancer was analyzed prospectively.
Laparoscopic para-aortic and pelvic lymphadenectomy was performed in 150 patients with cervical (n = 96), endometrial (n = 41), or ovarian cancer (n = 13). Lymphadenectomy was combined with laparoscopically assisted vaginal radical hysterectomy in 70 patients, with laparoscopically assisted vaginal hysterectomy and/or bilateral salpingo-oophorectomy and/or appendectomy and/or omentectomy in 24 patients, with trachelectomy in 2 patients, and with laparoscopic radical hysterectomy in 2 patients; lymphadenectomy alone was performed in 52 patients. Right-sided para-aortic lymphadenectomy extended to the level of the right ovarian vein; left-sided dissection reached the level of the inferior mesenteric artery. In ovarian tumors, dissection was extended to the level of the renal vessels; in addition, the ovarian vessels were removed with the surrounding tissue. Peri- and postoperative data were collected prospectively to monitor progress of surgical performance.
Mean operative time was 36 min (15-105 min) for right-sided para-aortic and 24 min (12-49 min) for left-sided para-aortic lymphadenectomy; bilateral pelvic lymphadenectomy took 64 min (44-110 min). On average 26.8 (10-56) pelvic lymph nodes and 7.3 (0-19) para-aortic lymph nodes were sampled. Major vessels were injured in 7 patients of which 4 patients required laparotomy. Patients undergoing lymphadenectomy alone were admitted for 3.2 days on average.
Laparoscopic para-aortic and pelvic lymphadenectomy is effective for staging and treatment of gynecologic cancers.
Gynecologic Oncology 11/1998; 71(1):19-28. · 3.89 Impact Factor
