Introduction

The surgical approach to hysterectomy for ovarian cancer has remained largely unchanged since Hudson described the en-bloc resection of fixed ovarian tumors using a retrograde technique in 1968. When a colorectal resection is required for optimal debulking, anastomotic leak remains a significant concern. While the traditional techniques used to evaluate for anastomotic perfusion lack accuracy, data from a recent systematic review and meta-analysis favours the use of ICG intra-op to reduce the incidence of anastomotic leak and associated need for re-intervention.

Description

The video aims to present the surgical steps to a Hudson procedure with colorectal resection, ending with the use of ICG fluorescence to assess the perfusion of the colorectal anastomosis and ureters. The surgical approach can be summarized in the following ten steps: (1) retroperitoneal dissection of the vascular pedicles and ureters, and transection of the IP ligament; (2) dissection of the paravesical and pararectal spaces; (3) lateral and pre-vesical peritonectomy; (4) ureterolysis and transection of the uterine vessels; (5) transection of the vesciouterine and uterosacral ligaments; (6) colpotomy; (7) mesorectal dissection and distal rectal transection; (8) proximal rectosigmoid transection; (9) vaginal vault closure and colorectal anastomosis; (10) assessment of colorectal anastomosis and ureteral vascularization by ICG fluorescence.

Conclusion/Implications

This video presented 10 reproducible steps to perform a Hudson procedure with colorectal resection for ovarian cancer. The use of ICG as an adjunct to assess the vascularization of the colorectal anastomosis appears to reduce the risk of anastomotic leak in colorectal surgery, and may be of interest in gynecologic-oncologic surgery.

Introduction

Total mesometrial excision is a surgical technique used for compartmental excision of mesometrium combining the radicality in the clearance of nodes and preserving the hypogastric plexus of nerves. This technique is indicated in the surgical treatment of early cervical cancers.

Description

This surgical film demonstrates the technique of total mesometrial excision of cervical cancers. The operation begins with retroperitoneal access, pelvic lymphadenectomy, dissection, and clearance of vascular and ligamentous mesometrium while preserving and safeguarding the ureter. This operation also includes the clearance of second echelon nodes from pre-sacral and common iliac nodal basins.

Conclusion/Implications

Total mesometrial excision involves the development of embryological planes around the Mullerian compartment with adequate clearance of paracervical and parakolpos for appropriate surgical management of cervical cancer. Adherence to the surgical principles and replication of classic techniques can minimize the morbidity associated with the radicality of the operation.

Introduction

This video aims to demonstrate a technique for safe and easy en bloc pelvic lymphadenectomy, focusing on the vesicohypogastric fascia. Our technique make surgeons to perform simple and safe for bleeding and obturator nerve injury.

Description

・Dissecting the lymph node from the vesicohypogastric fascia, and external iliac vessels from the iliopsoas muscle

・Dissecting the vascular sheath of external iliac vessels

・Split adipose tissue and check the obturator nerve from the medial side

・Ligate external/internal inguinal nodes and the obturator artery and vein

・Dissecting the nodes of the levator ani muscle

・Dissecting the internal iliac artery and bifurcation of the internal and external iliac arteries

・Ligating the common iliac lymph node

・Dissecting from the origin of inferior gluteal vessels

・Dissecting the lymph node from the vesicohypogastric fascia

Conclusion/Implications

Key surgical concepts are that first, dissection of the medial and lateral borders, checking the obturator nerve on the caudal side, and dissection of the iliac artery bifurcation at late lymphadenectomy stages. Under the bifurcation, under the origin of obturator artery, there are lumbosacral trunk, gluteal vein. We should be conscious about these structures to avoid injury. Vesicohypogastric fascia is used as “natural retractor” for lymphadenectomy in minimally invasive surgery.

Introduction

Use of laparoscopic staging surgery for localised endometrial cancer requires a thorough knowledge of the deep pelvic spaces. This gains more importance for cases with variant and uncommon pathology with variable involvement of parametrium.

Description

This video vignette highlights a smooth conduct of a similar staging procedure and focusses on the principles of total meso-metrial excision for high risk endometrial cancer. Our patient is a 62 years lady presented with post-menopausal vaginal bleeding. Endometrial biopsy showed a poorly differentiated carcinoma. Staging MRI showed disease limited to uterus with suspicious extension into parametrium. She underwent Laparoscopic Type II radical hysterectomy with bilateral pelvic lymphadenectomy and para-aortic lymph node sampling. Specimen was retrieved via vaginal route. Total blood loss was 300mL. Patient was discharged on post-operative day 3. Histopathology report showed serous carcinoma of the endometrium with free margins and no metastases to pelvic and retroperitoneal lymph nodes.

Standardized conduct of an adequate staging surgery for endometrial cancer includes sequential conduct of the following steps:

Total mesometrial excision with bilateral pelvic lymphadenectomy

Dissection of the round ligament and infundibulo-pelvic ligament

Dissection of lateral para-vesical space and obturator space

Dissection of medial para-vesical space

Ligation of uterine artery at origin from internal-iliac artery

Dissection in Mackenrodts’ tunnel

Vaginal cut & Specimen delivery

Vault closure

Para-aortic lymph node dissection

Infra-colic omentectomy (as indicated)

Conclusion/Implications

Orientation to anatomy of the deep pelvic spaces helps in a systematic conduct of a technically challenging procedure.

Introduction

Ovarian neoplasms are common gynecological problems affecting females of all ages. Rapidly growing masses with malignant potential require surgical management. Avoiding the leakage of cystic contents for tumors has become a challenge. Therefore, exploratory laparotomy has been the most common surgical method to minimize the risk of spillage and intraperitoneal seeding in cases of possible malignancy. However, large incisions are prone to infection, dehiscence, prolonged hospital stay, and patient recovery. As such, mini-laparotomy through decompression of ovarian neoplasms has been done.

This is a case of a 33-year-old nulligravid who sought consult due to increasing abdominal girth of five months with associated bloatedness and early satiety. Ultrasound showed an ovarian mass measuring 27.43 x 23.36 x 11.71cm with 1B and no M features by IOTA rules. The surgical plan was to do controlled decompression with limited tissue manipulation and tumor spillage using Dermabond Advance.

Description

An infraumbilical incision was done to expose the tumor surface. Dermabond was applied on an avascular area where a sterile glove was applied. A small incision was made at the base of the glove, adherent to the tumor, draining and collapsing the cyst, preventing spillage of tumor contents. Once the tumor was decompressed, it was exteriorized with the glove still attached. Left salpingo-oophorectomy was performed thereafter.

Conclusion/Implications

Our procedure provides further evidence of the safety and feasibility of spillage-free surgical techniques. Given the rarity of these conditions, other studies and cooperation among specialized centers are essential to define treatment standards.

Introduction

This case is stage IIIA1(ii) ovarian cancer, and when retroperitoneal lymph node dissection is performed, open surgery is usually performed if the size is large. The authors want to show that successful resection can be achieved using the laparoscopic approach.

Description

In this surgical method, before entering the abdominal cavity completely, only the peritoneum was left. The space was expanded to approach the retroperitoneal space. 4 ports were used, and advanced bipolar, articulating forceps and metal clips were used. The metastatic lymph node was present on the left side and was approached from the left side, and the area where the ureter enters the kidney did not expand. The root of the metastatic lymph node was in the space between the posterior renal vein and the anterior renal artery. After blunt dissection was performed around it, the root was ligated with a metal clip.

Conclusion/Implications

When operating ovarian cancer, open surgery is performed if it is not in the early stage. Also, when lymph node dissection is performed, a ventral approach is used, and the bowel is lifted at this time, which may cause postoperative pain and complications.
However, if the retroperitoneal approach (side or dorsal) is performed, a sufficient field of view can be secured without directly touching the bowel, and the length of the incision can be shortened, thereby reducing complications after surgery.
This surgical approach is considered to be a method that should be considered if it is any indication.

Introduction

Injury to common iliac vessels is uncommon during gynecologic cancer surgery. However, resection of encasing metastatic lymph nodes will increase the risk.

This video is representing a laparoscopic injury to the left common iliac vein during dissection of lymph nodes.

Description

How to repair a vessel injury laparoscopically :

- Don’t panic

- Try to identify the site of injury

- Chose the best angle to visualize the site of injury before starting the repair

- Use prolene suture

Conclusion/Implications

How to deal with such a challenging complication.

Introduction

Ovarian cancer is one of the most common gynecologic cancers and ranks eighth in mortality among women. More than 60% are detected in FIGO2018 stages III and IV. A complete cytoreduction is a significant prognostic factor. Eventual resection of liver implants becomes an essential knowledge for the surgical treatment of ovarian cancer.

Description

This video demonstrates surgical techniques using current surgical equipment for hepatic lobes mobilization, and access to the entire liver for non-anatomical resections. Initial mobilization of the right and left hepatic lobes is demonstrated, with division of the triangular and coronary ligaments. The falciform and the round ligaments are common sites of neoplastic involvement, and to reduce umbilical vessels bleeding, ligation of the round ligament was useful. After mobilization, we demonstrate the resection of Glisson's capsule implants, with manual hemostatic control and field exposure. Non-anatomical liver resections may benefit from an adequate vascular control of the hepatic hilum with a Pringle Maneuver. Manual and/or traction with stitches improve exposure for a nodule resection. Hemostasis was performed with Argon Beam energy (2;3). Surgical technique during laparoscopic resections is comparable, and in this video we used Ultrasonic scalpel with an active suction device exposure. Larger ducts and blood vessels should be clipped and ligated, and application of an hemostatic agent. Drainage was not indicated.

Conclusion/Implications

This video demonstrates reproducible standardized surgical techniques with simple materials for non-anatomical liver resections during ovarian cancer upper abdominal cytoreduction.

Introduction

THIS VIDEO WILL SHOW A ROBOTIC RESECTION OF A FUNDUS VAGINAL ADENOCARCINOMA AFTER 20 YEARS PREVIOUS HYSTERECTOMY FOR BENING DISEASE

Description

THIS VIDEO WILL SHOW THE TECHNIQUE OF ROBOTIC RESECTION OF SUPERIOR THIRD OF VAGINA TUMOR IN A PATIETNT THAT HAD 20 YEARS BEFORE A HYSTERECTOMY FOR BEING DISEASE.

Conclusion/Implications

DUE TO THE RARITY OF THE CASE AND THE POSSIBILITY OF DEMONSTING THE TECHNIQUE AND ANATOMY BY ROBOTIC WAY THE VIDEO BECOME INTERESTING FROM THE DACTICAL POINT OF VIEW.

Introduction

Radical trachelectomy is the universal treatment for patients with early-stage cervical cancer desiring to maintain fertility. The mean recurrence rate after trachelectomy is 3.3~3.7%. We demonstrated a single-port robotic hysterectomy to a patient with a history of robotic trachelectomy. The condition of the uterus and other organs, recovery status, and the difficulty of reoperation can be reviewed.

Description

A 32-year nulliparous with recurrence of cervical cancer received the single-port robotic hysterectomy with bilateral salpingectomy. 9 years ago, she had a multi-port robotic radical trachelectomy with pelvic lymphadenectomy for stage IA1 cervical cancer. In the first video, we described the multi-port robotic radical trachelectomy. In December 2021, her pap-smear revealed adenocarcinoma. In the second operation, we used the DaVinci SP system to perform the hysterectomy and bilateral salpingectomy. There was an adhesion between the uterus and the ovary due to the previous operation. The uterus and bladder had moderate adhesions and were carefully exfoliated. Upon completion of the colpotomy, the thread that had undergone cervical cerclage performed in the previous operation was confirmed. The subsequent procedures were like that of a typical hysterectomy.

Conclusion/Implications

Single port robotic hysterectomy after the trachelectomy is a safe and effective approach for cervical cancer recurring patients. Finding the incision margin between the uterus isthmus and the upper vagina was difficult as there was adhesion between the uterus and the bladder, also due to the absence of the cervix of the uterus.

Introduction

Giant ovarian neoplasms, described as tumors more than 20cms, have become rare due to the advent of modern imaging modalities. However, in low-resource settings, these neoplasms may still be missed. The limited number of cases poses management dilemmas in the absence of surgical guidelines.

Description

This presentation highlights the decompression technique using a purse-string suture in a 43 year-old with history of gradual and increasing abdominal girth. Ultrasound revealED a mass, benign by IOTA, measuring 53cms in diamenter, containing 42,000cc. Surgical approach was mini-laparotomy with decompression. With only a limited surface area exposed, a purse-string suture was carefully placed on the outer layer of the cyst wall, ensuring not to go through and through the entire wall thickness that may cause inadvertent spillage. The sutures were circumferentially placed, then a small incision was made within to drain the cyst. Once decreased in size, the ends of the suture were tied securing closure of the purse-string opening. The mass was then easily manipulated and exteriorized for removal. The surgical team proceeded to doing a left salpingoophorectomy followed by hysterectomy with right salpingoophorectomy. The patient tolerated the procedure well, recovering without complications commonly found in wide abdominal incisions.

Conclusion/Implications

Giant ovarian neoplasms often pose a dilemma on surgical approach. While laparoscopy is the gold standard, it has been associated with increased risk of spillage and longer operating time for giant neoplasms. Decompression technique using a mini-laparotomy incision allows the surgeon to have adequate exposure, without the risks of inadvertent perforation and spillage.

Introduction

To demonstrate of identifying one of the renal artery variant, triple renal artery in left during laparoscopic para-aortic lymphadenectomy.

Description

Patients: A 54-year-old Korean woman with postmenopausal bleeding and thickened endometrium> 3cm presented to our department. The histopathology of biopsied endometrium revealed grade 2 endometrioid adenocarcinoma. The preoperative MRI shows an about 6cm sized large volume of tumor within the endometrial cavity.

Interventions: We perform the laparoscopic staging surgery for endometrial cancer. Firstly we performed peritoneal washing cytology, LAVH, BSO, pelvic lymphadenectomy. We designated four area for para-aortic lymphadenectomy. During the procedure in area 4, it was confirmed that two left renal arteries were derived from the trunk of the aorta below the left renal vein. The left lower segmental artery was derived from the middle part of the inferior mesenteric artery and left renal vein. The middle segmental artery was derived just below left renal vein. The left main renal artery was located on the dorsal side of the left renal vein at its normal position. We carefully resected the para-aortic lymph nodes to prevent variant renal artery damage.

Conclusion/Implications

Laparoscopy is a feasible and safe approach to diagnosis of vascular anomaly during para-aortic lymphadenectomy for gynecologic malignancies. It is very important for the gynecologic oncologist to have knowledge of retroperitoneal vascular anatomy, experience in laparoscopic surgery, and an accurate surgical technique to avoid vascular injury during laparoscopic para-aortic lymphadenectomy.

Introduction

The usage of uterine manipulator should be avoided in order to prevent intrauterine seeding of tumor in pelvic cavity especially in endometrial cancer surgery.

At single site robotic surgery by Xi, it is difficult to use additional assisting robot arm other than one camera and 2 robot arms.

At single port robotic surgery by SP, we can use three robot arms other than one camera. But it is not easy to move or co-ordinate 3 robot arms for operator.

Description

We use blue cap, hegar(13) for immobilizing uterine cervix.

We use multi-articulating instrument, artisential, to move tissue in single site robotic surgery by Davinci Xi, and single port robotic surgery by Davinci SP. In both robot surgery, artisential is useful instrument to perform PLND hysterectomy without uterine manipulator.

Conclusion/Implications

Using multi-articulating instrument is reasonable option to perform PLND hysterectomy without uterine manipulator by counteraction done.

Introduction

the choice of the surgical technique during pregnancy include considerations of uterine and fetal safety along with minimizing spillage technique this film will demonstrate en efficient safe surgical technique for huge cystadenofibroma during pregnancy

Description

This video describe a simple effective surgical approach to huge cyst 17 litters during pregnancy.

The tips and tricks include didactic demonstration of pre-operative evaluation, minimizing spillage technique and pathological results.

Conclusion/Implications

This is an efficient quick surgical solution with minimal morbidity for huge adnexal cyst during pregnancy

Introduction

In high risk endometrial cancer after radical hysterectomy and systematic pelvic nodal dissection, para-aortic nodes dissection upto renal veins is required. If central docking is done, the arams don’t reach high par-aortic region upto renal veins, if side docking is done, it is not optimal for pelvic surgery. Most of the times, dual docking or change of position of both patient and robot is required. Intuitive recommended procedure card, ports placements fails to achieve this.

Description

So we describe modified port placement enabling both pelvic and para-aortic node dissection with the description of these procedure after radical hysterectomy in our video with single docking, single position and same port placement technique

Conclusion/Implications

This technique is advantages as it uses single docking and position with same ports for both pelvic and para-aortic nodal dissection, there by shortening the total time taken for the entire procedure and learning curve in the robotic surgeon.

Introduction

Removal of large ovarian cysts has a high risk of spillage. Various techniques have been described for benign cysts, using plastic self-retractors or a laparoscopic bag.

This video highlights a technique for safely draining and removing a large ovarian mass.

Description

86 years old woman presented with abdominal distension and intraabdominal pressure symptoms for 6 months in Covid19 pandemic. She was anorexic, severely anaemic requiring blood transfusions, with severe bilateral pedal oedema. The eGFR=38. CT demonstrated a large abdominopelvic mass, with intraabdominal compression effect. A 10 cm midline laparotomy was performed. The suction tube was connected to the gas inflow valve of the 5 mm laparoscopic port. DERMABOND ADVANCED^® skin adhesive was applied over the external area of the bowel bag. The cyst surface was dried. Further adhesive was applied over the cyst wall, followed by the bag, and a gentle pressure for 2 minutes for a good seal. Once complete coverage was secured, the port with the suction attached was inserted. Ten litres of fluid were aspirated, an 40x20 cm cyst removed, containing 4L of bloodstained fluid.

Conclusion/Implications

We recommend this technique because it is easy to perform, straightforward, and very simple in case of fluid filled enlarged ovarian cysts. The incision is small and there is a safe aspiration of the cyst contents. Patient’s recovery is fast. It can be used for benign cysts, known malignant cysts, where the dissemination is not of a concern, and in palliative cases where the performance status does not allow a more complex operation.

Introduction

More than 60% of all ovarian cancer patients are diagnosed in stages III and IV (FIGO 2018) (1). The vast majority will present upper abdominal disease, with splenic capsule, hilum or even parenchyma involvement. In this scenario, surgical techniques addressing partial or total splenectomy becomes an essential part of a complete cytoreductive surgery.

Description

This video demonstrates surgical techniques using routine materials for implants resection in the spleen, including partial and total splenectomy. The combination of preoperative imaging and surgical Peritoneal Carcinomatosis Index (PCI) evaluations may predict the precise technique indication. A posterior organ approach allows access to the splenocolic, splenophrenic, and splenorenal ligaments, which are identified and divided. Ligation of the short gastric vessels can be achieved with metallic clips or silk stitches. During a total resection due to parenchymal metastasis, dissection of the splenic hilum with ligation of the splenic artery followed by the splenic vein. We demonstrate two other cases with partial/capsular splenectomy with electrocautery and/or cold blade. Temporary clipping of the splenic vessels may be necessary for extended partial splenectomies, and will be described in another video.

Conclusion/Implications

This video demonstrates reproducible standardized techinques for total or partial splenectomy in ovarian cancer cytoreduction.

Introduction

There is a potential oncological benefit related to isolated recurrences surgical resection. The aim of this video is to demonstrate a prone position laparoscopic approach to posterior inferior mediastinal lymphadenectomy.

Description

The patient had been treated for a pelvic gynecologic poorly differentiated carcinoma with a sarcomatoid component, 4 years before this salvage procedure. She had received a pelvic lymphadenectomy and a total hysterectomy. Her nodal recurrence was detected during follow-up and partially responded to platin-based chemotherapy. After a multidisciplinary discussion, surgical resection was offered.

The patient was in a prone position, similar to the thoracic step for esophagectomy. Selective ventilation was followed by right side access (4 trocars). An anatomical review was performed as the pleural space was entered and the right lung collapsed with left selective ventilation. The dissection started with a mediastinal pleural dissection with regular bipolar and advanced bipolar, proximal to distal, from T10 to T12, between the thoracic aorta and the corpus vertebrae. Intercostal branches and azygos vein were preserved. All small vascular and lymphatic branches were sealed and/or clipped. The specimen was inserted into a bag and retrieved by the 12mm incision. A thoracic drain was placed. Surgical time was 96min, blood loss 12cc. Thoracic drain was retrieved on POD2 when the patient was discharged.

Conclusion/Implications

The laparoscopic prone surgical approach is safe, feasible, and standardized for the thoracic/upper digestive surgeon, and should be considered for posterior mediastinal approaches.

*This video was presented at AAGL 2021 annual meeting.