Page 25 - World Journal of Laparoscopic Surgery
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            undergo this surgical procedure with argon beam coagulation  In laparoscopy-assisted radical vaginal hysterectomy,
            and endoscopic staplers. Sixty-eight patients had squamous  laparoscopy is used to develop the paravesical and pararectal
            cell carcinomas; 8 patients had adenocarcinomas, and 2 patients  spaces. The cardinal ligament is isolated and cut after bipolar
            had adenosquamous carcinomas of the cervix.        coagulation to the level of the deep uterine vein. By the vaginal
                                                               approach, the ureters are identified before their entry into the
            Results:  All but 5 surgical procedures were completed
            laparoscopically. The average operative time was 205 minutes  bladder pillar. The uterine vessels are pulled down until their
            (range, 150-430 minutes). The average blood loss was 225 mL  laparoscopically coagulated ends become visible. After incision
            (range, 50-700 mL). One patient (1.3%) had transfusion.  of the vesicocervical reflection, the uterine fundus is grasped
            Operative cystotomies occurred for 3 patients: 2 cystotomies  and developed (Döderlein maneuver). The lower cardinal and
            were repaired laparoscopically, and 1 cystotomy required  uterosacral ligaments are exposed by pulling the cervix and
            laparotomy. One patient underwent laparotomy because of  fundus uteri to the contralateral side. The cardinal and
            equipment failure, and another patient underwent laparotomy  uterosacral ligaments are dissected and ligated, and the
            to pass a ureteral stent. Two other patients underwent  specimen is removed. We combined laparoscopic
            laparotomy to control bleeding sites. All surgical margins were  lymphadenectomy with radical vaginal hysterectomy in 33
            macroscopically negative, but 3 patients had microscopically  women with cervical cancer. The mean operating time was 80
            positive and/or close surgical margins. One patient had a  minutes for the vaginal phase and 215 minutes for the
            ureterovaginal fistula. There have been 4 documented  laparoscopic phase, including para-aortic and pelvic
            recurrences (5.1%), with a minimum of 3 years of follow-up. 3  lymphadenectomy and preparation of the cardinal ligaments.
                                                               Blood transfusions were necessary in four women. Three
            STUDY DESIGN–2                                     patients sustained injury to the bladder, one patient to the left
                                                               ureter, and another patient to the left internal iliac vein. Repair
            A type III radical hysterectomy with bilateral aortic and pelvic  was achieved at primary surgery for all intraoperative
            lymph node dissection was separated into eight component  complications. No fistula was observed. The patients had fully
            parts: (1) right and left aortic lymphadenectomy, (2) right and
            left pelvic lymphadenectomy, (3) development of the paravesical  recuperated after a mean of 28 days. The laparoscopy-assisted
            and pararectal spaces, (4) ureteral dissection, (5) ligation and  Schauta-Stoeckel approach may prove to be a safe alternative
                                                                                                      6
            dissection of the uterine artery, (6) development of the  to conventional radical abdominal hysterectomy.
            vesicouterine and rectovaginal spaces, (7) resection of the  A vaginal or a laparoscopic approach in radical surgery for
            parametria, and (8) resection of the upper vagina. The adequacy  cervical carcinoma has been proposed. A pilot study of eight
            of the component parts was determined and documented on  cases shows that an oncologic surgeon familiarized with these
            video.                                             techniques is able to take advantage of the benefits of both
                                                               routes in the same patient: Laparoscopic surgery is adapted to
            Results: Complete aortic and pelvic lymphadenectomy and a  lymph node dissection, section of the origin of the uterine artery,
            type III radical hysterectomy were performed by operative  and dissection of the ureter under direct vision; vaginal surgery
            laparoscopy.                                       allows a precise incision of the vaginal cuff. Both routes may be
            Conclusion: A complete pelvic and aortic lymphadenectomy  used for the section of parameters, but we propose the use of
            and type III radical hysterectomy were performed   the vaginal route. The combination of vaginal and laparoscopic
            laparoscopically. This approach could potentially decrease  surgery spares the pain and discomfort of both laparotomy and
            morbidity historically associated with radical hysterectomy and  perineotomy. 7
            lymphadenectomy performed either abdominally or vaginally.  The clinical usefulness of laparoscopic pelvic and para-
            Only prospective randomized trails will allow for the evaluation  aortic lymphadenectomy for staging and therapy of
            of potential benefits associated with this surgical technique. 4  gynecological cancer was analyzed prospectively.
               Fourteen cases of radical hysterectomy with bilateral pelvic
            and common iliac lymphadenectomy for a stage IB squamous  Method: Laparoscopic para-aortic and pelvic lymphadenectomy
            carcinoma of the cervix. To date fourteen of these procedures  was performed in 150 patients with cervical (n = 96), endometrial
            have been performed with few complications. The complications  (n = 41), or ovarian cancer (n = 13). Lymphadenectomy was
            encountered thus far include narrowing of a right ureter  combined with laparoscopically assisted vaginal radical
            detected by an intravenous pyelogram obtained on   hysterectomy in 70 patients, with laparoscopically assisted
            postoperative day 10 and a small vesicovaginal fistula. The  vaginal hysterectomy and/or bilateral salpingo-oophorectomy
            narrowed right ureter had a retrograde stent placed as a  and/or appendectomy and/or omentectomy in 24 patients, with
            precaution. It would appear that laparoscopic radical  trachelectomy in 2 patients, and with laparoscopic radical
            hysterectomy in selected patients offers significant advantages  hysterectomy in 2 patients; lymphadenectomy alone was
            in terms of hospitalization, incision size, and wound, pulmonary,  performed in 52 patients. Right-sided para-aortic
            and intestinal complications. In addition to the clinical  lymphadenectomy extended to the level of the right ovarian
            advantages, laparoscopic radical hysterectomy appears to be  vein; left-sided dissection reached the level of the inferior
            more cost effective than traditional laparotomy. 5  mesenteric artery. In ovarian tumors, dissection was extended
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