Introduction

Volume of residual disease following cytoreductive surgery for patients with advanced ovarian, fallopian tube, and peritoneal carcinoma is one of the most important factors for overall survival. Extensive upper abdominal resections was not initially part of the surgical armamentarium of advanced ovarian cancer management for Gynecologic Oncologists. Large-volume upper abdominal tumor involving the diaphragm, liver, and/or spleen was deemed “unresectable,” and the patient was left with suboptimal residual disease. The incorporation of upper abdominal comprehensive surgical techniques has led to a significant improvement in optimal cytoreduction rates, and ultimately improved progression-free and overall survival.

Description

In this film we demonstrate the steps of open abdominal radical debulking surgery for high-grade ovarian carcinoma including a splenectomy, pancreatectomy, and full thickness diaphragm resection with excision of a cardiophrenic lesion. We also demonstrate potential complications as well as strategies to repair and limit these.

Conclusion/Implications

This surgical film demonstrates the feasibility and techniques involved for performing a splenectomy, pancreatectomy, and full thickness diaphragm resection with excision of a cardiophrenic lesion. Additionally, we demonstrate strategies to limit and manage post-operative complications associated with these surgeries. We hope this video will provide physicians with tools to incorporate into their practice in order to improve outcomes for their patients.

Introduction

Introduction

The vaginal morbidity caused by radical surgeries and, or radiotherapy is a significant distress cervical cancer treatment-related. Developing techniques that can reestablish sexual function is essential for providing a better quality of life for those patients.

Description

The purpose of this video is to highlight a robotic-assisted modified Martius fasciocutaneous flap technique for vaginal reconstruction.

A 27-year-old patient, FIGO IIIC1 cervical carcinoma referred for concurrent platinum-based chemoradiation and treated successfully. After treatment, she developed severe vaginal stenosis becoming unable to have vaginal sexual intercourse.

Five years later, she underwent vaginal reconstruction using two simultaneous approaches—an abdominal robotic total hysterectomy with bilateral salpingo-oophorectomy and total colpectomy. Perineal access was used to make a modified Martius fascio-cutaneous flap to create the neovagina. The distal portion of the neovagina was attached to the remaining uterosacral ligaments robotically. The surgery took 4 hours and the patient was discharged from hospital on the next day. She recovered well and in the follow up visit, the measurement of the neovagina was 9 cm. She successfully had sexual relations with penetration 6 months after the procedure.

Conclusion/Implications

The primary purpose of this video article is to demonstrate the step by step technique of the modified Martius fasciocutaneous flap as an alternative vaginal reconstruction for patients with severe vaginal stenosis after being treated with radiotherapy or radical primary surgical procedure. This technique is relatively simple and has minor morbidity, allowing the gynecologist to restore the patient’s sexual function without engaging other types of specialists in the procedure.

Introduction

The purpose of this study is to introduce robotic radical hysterectomy with tagged uterine suture instead of using a uterine manipulator or vaginal tube.

Description

A total of 4 ports were used; first port was located left at 8cm from umbilicus, second port was 20mm sized at umbilicus, third port was located right at 8cm from umbilicus, and fourth was located right at 8cm from the third port (near the right flank). Uterus was tied with needle-straightened multifilament Vicryl 2-0 and tagged uterus was manipulated by fourth arm of the robot. If additional traction is required, instrument was inserted though the umbilical trocar site.

During operation, the tagged uterus was successfully manipulated and appropriate parametrial space was exposed. Pathologically, all surgical margins were not involved with cancer. No tumor cells were seen in cytologic exam before and after the colpotomy.

Conclusion/Implications

Robotic radical hysterectomy can be easily and safely done with the traction of tagged uterine suture.

Introduction

This is a 65-year-old female with history of invasive rectosigmoid adenocarcinoma status post low anterior resection complicated by anastomotic dehiscence and pelvic abscess. She underwent sigmoidoscopy with closure of dehiscence with Endo suture. Patient was asymptomatic for 3 years when she presented with rectovaginal fistula, status post failed attempted sigmoidoscopy with Endo suture.

Description

Under general anesthesia first cystoscopy was perfomed and ureteral catheters were places and indocyanine green was injected for identification of the ureters . Uterine manipulator with cup was placed to assist in identification of the rectovaginal space. Laparoscopic portion of the operation started with mobilization of the omentum from the hepatic flexure for later use. Using the images technology ureters were identified and proceeded with posterior cul-de-sac dissection to identify the fistula tract. After the fistula track was identified, surgical clips and sutures from previous failed repair were removed. The rectovaginal space was fully developed and necrotic and nonviable tissue from the vagina and rectal edges were completely removed . Placement of the uterine manipulator in the vagina and the rectal sizer in the rectum facilitated identification of these two organs better. The vagina was closed transversely with one layer of 0 barb sutures and rectum was close in two layers. Finally, mobilized omentum was brought down and placed and secured between the rectum and vagina.

Conclusion/Implications

Patient had no complication intraop and postop and was discharged home on postop day 2. She was seen 2 and 6 weeks postop with no fistula recurrence and is doing well.