Journal of minimally invasive gynecology最新文献

Objective: Endometriosis is a chronic and inflammatory condition that affects approximately 10% of the reproductive-age population. During the COVID-19 pandemic, there was a shift towards virtual care for endometriosis. Our aim was to evaluate the diagnostic and treatment outcomes of virtual-only care, compared to those who had both virtual and in-person visits.

Design: Retrospective descriptive analysis of registry data.

Setting: This study was conducted in British Columbia, Canada, at a tertiary referral center for endometriosis and pelvic pain.

Participants: In this cohort (n=389), we examined patients who received an initial virtual assessment followed by virtual care alone (Virtual Only group, n=203) and those who had an initial virtual assessment followed by an in-person physical exam (Physical Exam group, n=186).

Interventions: Virtual care at the center during the Covid-19 pandemic.

Results: The Physical Exam group was more likely to have surgery compared to the Virtual Only group (45.7% vs. 16%, p<.001). At the time of surgery, the groups did not differ based on type of surgery (e.g. excision of endometriosis and/or hysterectomy), endometriosis anatomic findings (e.g. stage and anatomic subtype), surgical complexity or surgical complications. At baseline, the two groups did not differ in their pain, mental health or quality of life scores. At one-year follow-up, the two groups did not differ in these outcome measures.

Conclusion: There was a lower rate of surgery, but no differences in surgical findings or complications, nor in one-year outcomes, after virtual only care for endometriosis compared to patients that had a virtual visit and then underwent a physical exam. These results support a hybrid model, where a virtual visit is the first contact and serves as a triage tool to determine whether a patient is appropriate for virtual only care or would benefit from a physical exam. Future research could incorporate population-based administrative data or qualitative approaches to understanding patient experiences and physician perspectives on virtual care for the treatment of endometriosis.

A 26-year-old nulliparous woman with lower abdominal pain, mildly elevated inflammatory markers, normal tumor markers and sonographic findings of an 11.9 × 6.1 cm cystic structure in the right adnexa, was treated with antibiotics for suspected hydrosalpinx. Over two years, subsequent ultrasounds demonstrated progressive cystic enlargement (Fig 1), with dimensions of 11.6 × 26 cm on CT imaging. Although her pain was mild, laparoscopic removal was recommended given the size of the pathology, which the patient consented to. At laparoscopy, a giant hydrosalpinx (Figure 2A), torted 3.5 times at the ampullary region (Figure 2B) was noted. Hydrotubation of the left tube demonstrated substantial resistance to flow (Figure 2C). Following fluid aspiration and detorsion of the right fallopian tube, the serosa was incised using bipolar coagulation to expose the lumen. Careful dissection was performed to separate and excise the serosal layer toward the uterine cornua. Non-absorbable sutures were placed at the interstitial-isthmic junction, and both tubes were subsequently resected [1]. Efforts were made to preserve blood supply between the ovaries and fallopian tubes throughout the procedure. Pathology confirmed bilateral chronic salpingitis, with normal Anti-Müllerian Hormone (AMH) levels. Giant hydrosalpinx is rare and presents substantive diagnostic and management challenges, particularly for young, nulliparous women desiring to conceive. These cystic structures can easily be misdiagnosed as ovarian cysts, making comprehensive imaging essential for accurate diagnosis [2-3]. Although this patient experienced mild symptoms, she developed isolated tubal torsion. Active management of large, persistent, or complex adnexal masses is often warranted and may necessitate surgical intervention. Surgical management focuses on preserving ovarian reserve to improve subsequent birth rates following in vitro fertilization (IVF) [4]. A retrospective clinical study [1] indicates that cornual suturing during salpingectomy may reduce ectopic pregnancy rates from 7.24% to 2.39%. Further validation through randomized controlled trials is necessary.

Study objective: To demonstrate a deep robotic dissection of the sacrospinous ligament due to suture abscess after failed vaginal approach.

Design: A stepwise demonstration of the procedure and critical anatomy with narrated video.

Setting: Tertiary care academic center. A 71-year-old patient with a pelvic abscess noted on magnetic resonance imaging with persistent vaginal bleeding after sacrospinous ligament suspension using permanent, multi-filament suture. Despite multiple vaginal attempts to remove the suture, the abscess and suture persisted. Decision was made to proceed with a robotic exploration.

Intervention: Sacrospinous ligament suspension is a procedure supporting the vaginal apex by securing it to the sacrospinous ligament, typically on the right side. It is a durable, native tissue repair performed through extraperitoneal vaginal dissection of the pararectal space. With suture related complications, to release the stitch, a vaginal approach is often successful and less invasive. However, it may be challenging to dissect this plane due to adhesions and difficult visualization. In this video, we demonstrate a robotic-assisted abdominal approach developing the pararectal space and identifying deep pelvic space lesions when vaginal attempts have failed. The top-down approach offers better visualization of surrounding critical structures, overcoming the limitations of the vaginal approach with limited visualization. However, this requires advanced knowledge and comfort with deep retroperitoneal structures.

Conclusion: The robotic approach offers an alternative to the vaginal approach and should be considered when the vaginal approach fails or is considered not feasible.

Study objective: To demonstrate the feasibility of performing single-port robotic assisted sacrocolpopexy.

Design: Step-by-step description of the surgical procedure using a narrated video.

Setting: Sacrocolpopexy is considered the gold standard for the apical prolapse. However, traditional laparotomic and laparoscopic approaches have limitations, including prolonged operation time, limited visualization, high morbidity, steep learning curve and poor ergonomics with difficulties in repeated suturing using rigid, straight laparoscopic instruments. The single-port robotic platform requires only a single incision measuring 2.5 to 3.5cm, and has started to be used in sacrocolpopexy providing several advantages as shown in the following video (1). Its articulating instruments and camera facilitate the procedure by providing optimal visualization and working space, even in challenging surgical fields, while minimizing collisions within a narrow 2.5cm trocar (2-4). The operation in this video was performed at a tertiary teaching hospital and demonstrates technical feasibility showing how the articulating instruments and camera facilitate the procedure.

Interventions: This video demonstrates a single-port robotic sacrocolpopexy using the da Vinci SP® system. The procedure was performed on a 74-year-old patient with stage 4 apical prolapse. Several advantages are appreciated. Collaborative handling of three working arms through a single 2.5 cm incision and trocar is unique to this robotic platform. Intracorporeal suturing and retroperitoneal tunneling is facilitated by the articulating instruments (3,5). Enhanced visualization of narrow spaces is noted using the articulating camera. Surgeon controlled suction and irrigation tube is used, eliminating the need for an additional port.

Conclusion: Single-port robotic assisted sacrocolpopexy is a feasible and novel option for treating apical prolapse.

Introduction: Epithelial ovarian cancer (EOC) is a significant global health concern. Early detection remains rare, with only 20% of cases identified at an early stage, highlighting the critical need for effective staging interventions¹. Traditional extensive lymphadenectomy, associated with considerable morbidity, has led to the exploration of selective sentinel lymph node biopsy (SLNB), which is still under study ^1,2,3,4.

Methods: SLNB, enhanced by robotic technology, is demonstrated through two clinical case studies studies that show how robotic systems are used to meticulously identify and map sentinel nodes, focusing on procedural specifics and fluorescence-guided node identification. The article synthesizes insights from recent studies^1,2,3,4, emphasizing the integration of robotic technology with SLNB to enhance surgical precision, improve recovery, and reduce morbidity.

Discussion: We examine SLNB through retroperitoneal and transperitoneal approaches, highlighting technical aspects and the benefits of robotic assistance over conventional laparoscopy, such as improved precision and ergonomics. A recent analysis and meta-analysis¹ showed a high pooled detection rate, though the evidence quality is low. Recently, the MELISA³ and SELLY² studies were published, with MELISA showing higher detection, sensitivity, and specificity rates than SELLY. Sentinel lymph nodes vary in location, requiring meticulous exploration¹. The retroperitoneal approach might offer an advantage for para-aortic dissection, particularly in obese patients, however, in sentinel lymph node biopsy, the need for extensive dissection could potentially limit its use⁵. Key technique aspects include injection zones and using combined tracers². Limitations include variable detection rates, lack of standardized protocols, accessibility to robotic technology, and the need for advanced surgical skills¹.

Conclusion: SLNB, particularly with robotic assistance, shows promise for improving accuracy and reducing morbidity in epithelial ovarian cancer. However, its use remains limited to clinical trials. Future studies should focus on developing standardized protocols to achieve consistent results and provide sufficient evidence for its integration into routine clinical practice.