Robotic Inferior Mesenteric Artery, Common Iliac Artery, and Retroperitoneal Lymph Node Dissection

David Schwartzberg MD, Tushar Samdani MD, FASCRS, Mario M. Leitao MD, FACOG, FACS, Garrett M. Nash MD, MPH, FACS, FASCRS

Recent data has shown an improved survival with metastasectomy for metastatic rectal cancer. Metastasectomy on a minimally invasive plateform (robotic) can be used for an R0 resection in patients who have retroperitoneal metastasis from rectal cancer after control of the primary tumor.

DOI # http://dx.doi.org/10.17797/wd7d09sjgc

Laparoscopic Right Salpingo-oophorectomy in a patient at 17 weeks gestation

Introduction:

The prevalence of adnexal masses in pregnancy ranges from 0.05 to 2.4 percent and approximately 1 to 6 percent of these masses are malignant. Patients typically present on prenatal ultrasound asymptomatically but some can have abdominal and back pain as well. Concerns for the fetus and complications in pregnancy cause surgeries to be postponed until after delivery; however, some adnexal masses require evaluation for malignancy.

We present a case of a 28-year-old female with a cystic adnexal mass that required laparoscopic salpingo-oophorectomy at 17 weeks gestation.

Methods:

After the patient was prepped and draped,the initial laparoscopic port was placed in the left upper quadrant, 3 cm below the costal margin and in the midclavicular line. This area, known as Palmer’s point, was chosen as the site for the initial port placement in order to avoid the gravid uterus. After intraperitoneal placement, the abdomen was insufflated with CO2 gas. Laparoscopic ports were placed at the umbilicus and in the right lower quadrant under direct visualization. The port placed at the umbilicus was an Applied Medical GelPOINT Advanced Access Platform. The entire abdominal and pelvic cavities were examined for any lesions. An initial washing was done to examine for malignant cells. The left ovary was examined and determined to be normal. The right ovary was noted to be enlarged, to approximately 10 cm, and was displaced into the posterior cul de sac. Next the infundibulopelvic ligament, broad ligament, ovarian vessels, and ureter are identified. The ureter, which is typically able to be identified at the pelvic brim where it crosses over the bifurcation of the iliac vessels and passes medially, was noted to be well below the plane of dissection. If the ureter is unable to be located trans-peritoneally, a peritoneal incision can be made parallel to the ovarian vessels and the ureter located retroperitoneally in the medial leaflet of the broad ligament. The right fallopian tube and right utero-ovarian ligament were transected using the Ligasure bipolar device. We evaluated for hemostasis of the pedicles. The right suspensory ligament of the ovary containing the ovarian vessels was then isolated and cauterized and transected using the Ligasure bipolar device.  A laparoscopic retrieval bag was introduced through the GelPOINT advanced access platform, the specimen was placed in the bag, and then the bag was brought to the surface of the patient’s abdomen. We were able to drain straw colored fluid from the cyst with the cyst contained safely within the bag. The remainder of the specimen was then able to be removed, contained within the bag. The patient’s abdomen was deflated and the ports were removed. The fascia at the umbilicus was closed with an 0 Vicryl (polyglactin) suture so as to avoid herniation at the site of the larger incision accommodating the GelPOINT. The rest of the ports were closed using subcuticular sutures.

Discussion:

Pathology revealed a mature cystic teratoma. The patient was discharged home on the same day of surgery with no complications. Fetal heart tones were within normal limits pre- and post-procedure. Laparoscopic surgery is a safe treatment for pregnant women with non-obstetrical surgical issues, including adnexal masses.

Hysteroscopic Treatment of Angular Pregnancy

A 30-year-old female underwent in-vitro fertilization and preimplantation genetic testing. The patient conceived after her first frozen embryo transfer (FET). Beta-hCG was measured at 85 and was doubling appropriately. Ultrasound showed an angular pregnancy with heart beat confirmed by MRI. The patient has a deep arcuate uterus which may have predisposed to angular pregnancy. She was given 3 doses of methotrexate unsuccessfully. Due to concern of rupture, she underwent a hysteroscopic injection of methotrexate inside the gestational sac at 7 weeks. Hysteroscopy showed the gestational sac within the angular portion of the uterus as well as the needle penetrating the gestational sac to inject the 50mg methotrexate (see video). Fetal heart rate ceased and the patient passed products of conception 1 week later. The patient had no further complications and had a normal pregnancy on her next FET that resulted in a livebirth.

Vulvar Condyloma Wide Local Excision with use of SONOPET

Ultrasonic aspiration (UA) is commonly used for resecting intracranial tumors, as they allow for debulking of large tumors, while avoiding damage to adjacent brain tissue. There are multiple models on the market from several different manufactures, Integra’s CUSA, Söring’s LEVICS, and Stryker’s SONOPET, being the three most studied (A Borges1, 2019).

This technique is also highly effective when employed for excisions in anogenital cases (Henzi, 2019), and is growing in popularity. Some of the most common diseases treated with SONOPET include VIN 2 (41.79%) and VAIN 2 (40.62%) (Henzi, 2019). Patient’s can have complete excision of the lesion with the benefit of less disfiguration and scarring compared to traditional wide local excision (WLE), with the most commonly reported complication being post-operative pain. Because SONOPET allows for aspiration and collection of fragmented tissue, tissue diagnosis can be achieved and has found to be consistent with pre-operative biopsy diagnosis. However, since margins cannot be confirmed it is not recommended when malignant disease is suspected (Miller, 2002).

The purpose of this video is to briefly review assembly and use of the Striker SONOPET for excision of vulvar lesions.

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