Abstract
Objective
Using an ultra-mini-wound technique to dissect the adhesion surrounding the umbilicus port site aiding laparoscopic staging surgery for treating a woman with an early-stage endometrioid endometrial cancer (E-EC) who had widespread and extensive abdominal adhesions secondary to the previous complicated cesarean section (C/S) and bladder rupture.
Case Report
A 70-year-old woman with a history of a previous C/S and complicating bladder rupture treated with the Boari flap repair, leaving a longitudinal depressed scar over the abdomen from the umbilicus site to pubic hair area in her 30s was scheduled for laparoscopic staging surgery due to early-stage E-EC. We performed an ultra-mini midline incision (3-cm) crossing the umbilicus to manually dissect the adhesion surrounding the umbilicus and inserted the main trocar port to establish the workplace for further laparoscopic staging surgery. Additionally, malposition of the right ureter (passing through the dome of the abdominal cavity) secondary to previous Boari flap repair for ruptured urinary bladder was clearly identified. Surgery was completed and uneventful. The patient was discharged on the day 4 with a total length of hospital stay of four days. She is living well and freeing of disease and sequelae.
Conclusion
An ultra-mini wound assisted laparoscopic surgery can be successfully applied in women with an extensive and widespread abdominal adhesion without increasing adverse events or prolonging length of hospital stay.
Introduction
The minimally invasive surgery (MIS) has become one of the most popular surgeries in management of women with either benign or malignant gynecological diseases [ ], although some controversies are existed and long-term outcomes are debated, particularly for those patients with cervical and/or advanced ovarian cancers or other uncertain complicated abdominal situations, such as unstable vital signs [ ]. Besides the aforementioned concerns, some other conditions may be associated with potential limitation of using MIS for surgery. Therefore, the potential challenges and/or limitations of MIS are crucial to be evaluated. One such challenge is the safety of laparoscopic entry in patients with previous abdominal surgery accompanied with widespread and advanced abdominal adhesion [ ].
Cesarean delivery (CD) is the most common surgery in women, and the adverse events (AEs) or complications of CD include the immediate and subsequent (perioperative and postoperative) sequelae [ , ]. Similar to AEs and complications resulting from exploratory laparotomic surgery, such as the development of intra-abdominal adhesion, CD is also associated with adhesion, although it is often mild and not located on critical area. However, sometimes, severe unpredictable situations may occur, such as severe postpartum hemorrhage and visceral organ injury [ ]. Although the majority of these complications can be adequately managed, some of them will result in the severe sequalae, which not only impair the quality of life (QoL) but also interfere the future medical care, such as repeated surgery or conducting MIS. The following case report addressing this unusual severe sequalae which result in difficulty of perform MIS and significantly increased risk of surgical complications. To overcome this challenge, we used an ultra-mini-wound technique to dissect the adhesion surrounding the umbilicus port site and initiated a laparoscopic surgery to finish this complex surgery.
Case report
A 70-year-old woman was diagnosed as early-stage endometrioid endometrial cancer (E-EC). Tracing her history, she had a complicated CD with a big bladder perforation and defect of urinary bladder undergoing Boari flap repair for reconstruction in her 30s, leaving a longitudinal depressed scar over the lower abdomen, and the scar started 3 cm below the umbilicus and extended 15 cm in length to the pubic area. At 69 years, she was diagnosed to have an early-stage left breast cancer undergoing mastectomy and following tamoxifen treatment. One month before this diagnosis, she visited the outpatient clinics for experienced vaginal spotting for months. Ultrasound revealed the thickening endometrium, and pathology from endometrial sampling showed atypical glandular cells with scanty E-EC, grade 2. After shared decision-making, she opted to undergo definitive surgical intervention, such as staging surgery. However, due to her bad experience of previous operation history, she insisted in the favoring use of MIS approach in the management of the disease by evaluation by series of image evaluation, confirming tumor within the uterine cavity without invasion beyond the uterus (an early stage).
The surgery commenced, and upon direct insertion of the umbilical main trocar as usual attempted. However, after failure of several attempts by direct trocar insertion, the final direct insertion of the trocar was successful, but the laparoscopy cannot work due to presence of omentum and possible intestines over the entire operative field, including the periumbilical area, resulting in total obliteration and invisibility of the operative field ( Fig. 1 ).
By longitudinally extending the umbilical wound up to 3 cm as ultra-mini midline wound incision described before [ , ], we delicately separated the intestines and peritoneal wall using an ultra-mini exploratory laparotomy approach. After achieving a sufficient safe margin for applying the wound retractor and glove for air sealing, pneumoperitoneum was re-established and laparoscopic guidance surgery can be continued. An additional port was inserted on the left upper quadrant area (Palmer’s point), and the adhesions were further dissected, completely freeing the intestines from the abdominal wall via a laparoscopic approach.
After lysis of the adhesions, a tubular structure was observed on the right pelvic wall ( Fig. 2 ). The bladder was distended with normal saline to delineate its margins, revealing a rightward displacement toward the right pelvic sidewall. This was consistent with the results after the Boari flap procedure, which had transposed the ureter from the retroperitoneum into the peritoneal cavity and to the dome of the pelvic cavity [ ]. The tubular structure was identified as the right ureter, exhibiting good peristalsis under laparoscopic visualization. Following its identification, the surgery proceeded cautiously to avoid damage to the right ureter and a complete laparoscopic staging surgery with total laparoscopic hysterectomy, bilateral salpingo-oophorectomy and retroperitoneal lymph node dissection was finished. The final pathology showed the E-EC, grade 1, without identified risk factors as classified FIGO stage IA1 (2023) [ , ].
