Co-Director, Sanford School of Medicine of the University of South Dakota
Intraoperative ear injury Primary repair of injured organ/structure indicated Partial resection of injured organ/structure indicated Complete resection of injured organ/structure indicated; disabling acne 7 days past ovulation buy procuta 40 mg without a prescription. Intraoperative endocrine injury Primary repair of injured organ/structure indicated Partial resection of injured organ/structure indicated Complete resection or reconstruction of injured organ/structure indicated; disabling Life-threatening consequences; urgent intervention indicated Death Definition: A finding of damage to the endocrine gland during a surgical procedure acne icd 10 code order 10mg procuta amex. Intraoperative head and neck injury Primary repair of injured organ/structure indicated Partial resection of injured organ/structure indicated Complete resection or reconstruction of injured organ/structure indicated; disabling Life-threatening consequences; urgent intervention indicated Death Definition: A finding of damage to the head and neck during a surgical procedure acne cream buy procuta master card. Intraoperative hemorrhage - - Postoperative radiologic acne marks purchase procuta 40 mg on-line, endoscopic, or operative intervention indicated Life-threatening consequences; urgent intervention indicated Death Definition: A finding of uncontrolled bleeding during a surgical procedure. Intraoperative hepatobiliary injury Primary repair of injured organ/structure indicated Partial resection of injured organ/structure indicated Complete resection or reconstruction of injured organ/structure indicated; disabling Life-threatening consequences; urgent intervention indicated Death Definition: A finding of damage to the hepatic parenchyma and/or biliary tract during a surgical procedure. Intraoperative musculoskeletal injury Primary repair of injured organ/structure indicated Partial resection of injured organ/structure indicated Complete resection or reconstruction of injured organ/structure indicated; disabling Life-threatening consequences; urgent intervention indicated Death Definition: A finding of damage to the musculoskeletal system during a surgical procedure. Intraoperative neurological injury Primary repair of injured organ/structure indicated Partial resection of injured organ/structure indicated Complete resection or reconstruction of injured organ/structure indicated; disabling Life-threatening consequences; urgent intervention indicated Death Definition: A finding of damage to the nervous system during a surgical procedure. Intraoperative ocular injury Primary repair of injured organ/structure indicated Partial resection of injured organ/structure indicated Complete resection or reconstruction of injured organ/structure indicated; disabling Life-threatening consequences; urgent intervention indicated Death Definition: A finding of damage to the eye during a surgical procedure. Intraoperative renal injury Primary repair of injured organ/structure indicated Partial resection of injured organ/structure indicated Complete resection or reconstruction of injured organ/structure indicated; disabling Life-threatening consequences; urgent intervention indicated Death Definition: A finding of damage to the kidney during a surgical procedure. Intraoperative reproductive tract injury Primary repair of injured organ/structure indicated Partial resection of injured organ/structure indicated Complete resection or reconstruction of injured organ/structure indicated; disabling Life-threatening consequences; urgent intervention indicated Death Definition: A finding of damage to the reproductive organs during a surgical procedure. Intraoperative respiratory injury Primary repair of injured organ/structure indicated Partial resection of injured organ/structure indicated Complete resection or reconstruction of injured organ/structure indicated; disabling Life-threatening consequences; urgent intervention indicated Death Definition: A finding of damage to the respiratory system during a surgical procedure. Intraoperative splenic injury - Primary repair of injured organ/structure indicated Resection or reconstruction of injured organ/structure indicated; disabling Life-threatening consequences; urgent intervention indicated Death Definition: A finding of damage to the spleen during a surgical procedure. Intraoperative urinary injury Primary repair of injured organ/structure indicated Partial resection of injured organ/structure indicated Complete resection or reconstruction of injured organ/structure indicated; disabling Life-threatening consequences; urgent intervention indicated Death Definition: A finding of damage to the urinary system during a surgical procedure. Intraoperative venous injury Primary repair of injured organ/structure indicated Partial resection of injured organ/structure indicated Complete resection or reconstruction of injured organ/structure indicated; disabling Life-threatening consequences; urgent intervention indicated Death Definition: A finding of damage to a vein during a surgical procedure. Kidney anastomotic leak Asymptomatic diagnostic observations only; intervention not indicated Symptomatic; medical intervention indicated Severe symptoms; radiologic, endoscopic, or elective operative intervention indicated Life-threatening consequences; urgent operative intervention indicated Death Definition: A finding of leakage of urine resulting from breakdown of a kidney anastomosis (surgical connection of two separate anatomic structures). Large intestinal anastomotic leak Asymptomatic diagnostic observations only; intervention not indicated Symptomatic; medical intervention indicated Severe symptoms; radiologic, endoscopic, or elective operative intervention indicated Life-threatening consequences; urgent operative intervention indicated Death Definition: A finding of leakage resulting from breakdown of an anastomosis (surgical connection of two separate anatomic structures) in the large intestine. Pancreatic anastomotic leak Asymptomatic diagnostic observations only; intervention not indicated Symptomatic; medical intervention indicated Severe symptoms; radiologic, endoscopic, or elective operative intervention indicated Life-threatening consequences; urgent operative intervention indicated Death Definition: A finding of leakage resulting from breakdown of a pancreatic anastomosis (surgical connection of two separate anatomic structures). Pharyngeal anastomotic leak Asymptomatic diagnostic observations only; intervention not indicated Symptomatic; medical intervention indicated Severe symptoms; radiologic, endoscopic, or elective operative intervention indicated Life-threatening consequences; urgent operative intervention indicated Death Definition: A finding of leakage resulting from breakdown of a pharyngeal anastomosis (surgical connection of two separate anatomic structures). Prolapse of urostomy Asymptomatic; clinical or diagnostic observations only; intervention not indicated Local care or maintenance; minor revision indicated Dysfunctional stoma; elective operative intervention or major stomal revision indicated Life-threatening consequences; urgent intervention indicated Death Definition: A finding of displacement of the urostomy. Radiation recall reaction (dermatologic) Faint erythema or dry desquamation Moderate to brisk erythema; patchy moist desquamation, mostly confined to skin folds and creases; moderate edema Moist desquamation in areas other than skin folds and creases; bleeding induced by minor trauma or abrasion Life-threatening consequences; skin necrosis or ulceration of full thickness dermis; spontaneous bleeding from involved site; skin graft indicated Death Definition: A finding of acute skin inflammatory reaction caused by drugs, especially chemotherapeutic agents, for weeks or months following radiotherapy. The inflammatory reaction is confined to the previously irradiated skin, and the symptoms disappear after the removal of the pharmaceutical agent. Rectal anastomotic leak Asymptomatic diagnostic observations only; intervention not indicated Symptomatic; medical intervention indicated Severe symptoms; radiologic, endoscopic, or elective operative intervention indicated Life-threatening consequences; urgent operative intervention indicated Death Definition: A finding of leakage resulting from breakdown of a rectal anastomosis (surgical connection of two separate anatomic structures). Seroma Asymptomatic; clinical or diagnostic observations only; intervention not indicated Symptomatic; simple aspiration indicated Symptomatic, elective radiologic or operative intervention indicated - - Definition: A finding of tumor-like collection of serum in the tissues. Small intestinal anastomotic leak Asymptomatic diagnostic observations only; intervention not indicated Symptomatic; medical intervention indicated Severe symptoms; radiologic, endoscopic, or elective operative intervention indicated Life-threatening consequences; urgent operative intervention indicated Death Definition: A finding of leakage resulting from breakdown of an anastomosis (surgical connection of two separate anatomic structures) in the small bowel. Spermatic cord anastomotic leak Asymptomatic diagnostic observations only; intervention not indicated Symptomatic; medical intervention indicated Severe symptoms; radiologic, endoscopic, or elective operative intervention indicated Life-threatening consequences; urgent operative intervention indicated Death Definition: A finding of leakage resulting from breakdown of a spermatic cord anastomosis (surgical connection of two separate anatomic structures). Stomal ulcer Asymptomatic; clinical or diagnostic observations only; intervention not indicated Symptomatic; medical intervention indicated Severe symptoms; elective operative intervention indicated - - Definition: A disorder characterized by a circumscribed, inflammatory, and necrotic erosive lesion on the jejunal mucosal surface close to the anastomosis site following a gastroenterostomy procedure. Tracheal hemorrhage Minimal bleeding identified on clinical or diagnostic examination; intervention not indicated Moderate bleeding; medical intervention indicated Severe bleeding; transfusion indicated; radiologic or endoscopic intervention indicated Life-threatening consequences; urgent intervention indicated Death Definition: A finding of bleeding from the trachea. Tracheostomy site bleeding Minimal bleeding identified on clinical examination; intervention not indicated Moderate bleeding; medical intervention indicated Severe bleeding; transfusion indicated; radiologic or endoscopic intervention indicated Life-threatening consequences; urgent intervention indicated Death Definition: A finding of blood leakage from the tracheostomy site. Ureteric anastomotic leak Asymptomatic diagnostic observations only; intervention not indicated Symptomatic; medical intervention indicated Severe symptoms; radiologic, endoscopic, or elective operative intervention indicated Life-threatening consequences; urgent operative intervention indicated Death Definition: A finding of leakage resulting from breakdown of a ureteral anastomosis (surgical connection of two separate anatomic structures). Urethral anastomotic leak Asymptomatic diagnostic observations only; intervention not indicated Symptomatic; medical intervention indicated Severe symptoms; radiologic, endoscopic, or elective operative intervention indicated Life-threatening consequences; urgent operative intervention indicated Death Definition: A finding of leakage resulting from breakdown of a urethral anastomosis (surgical connection of two separate anatomic structures). Urostomy obstruction Asymptomatic diagnostic observations only; intervention not indicated Symptomatic; dilation or endoscopic repair or stent placement indicated Altered organ function. Urostomy site bleeding Minimal bleeding identified on clinical examination; intervention not indicated Moderate bleeding; medical intervention indicated Severe bleeding; transfusion indicated; radiologic or endoscopic intervention indicated Life-threatening consequences; urgent intervention indicated Death Definition: A finding of bleeding from the urostomy site. Urostomy stenosis - Symptomatic but no hydronephrosis, no sepsis or no renal dysfunction; dilation or endoscopic repair or stent placement indicated Symptomatic. Uterine anastomotic leak Asymptomatic diagnostic observations only; intervention not indicated Symptomatic; medical intervention indicated Severe symptoms; radiologic, endoscopic or elective operative intervention indicated Life-threatening consequences; urgent operative intervention indicated Death Definition: A finding of leakage due to breakdown of a uterine anastomosis (surgical connection of two separate anatomic structures). Uterine perforation Asymptomatic diagnostic observations only; intervention not indicated Symptomatic and intervention not indicated Severe symptoms; elective operative intervention indicated Life-threatening consequences; urgent intervention indicated Death Definition: A disorder characterized by a rupture in the uterine wall. Vaginal anastomotic leak Asymptomatic diagnostic observations only; intervention not indicated Symptomatic; medical intervention indicated Severe symptoms; radiologic, endoscopic, or elective operative intervention indicated Life-threatening consequences; urgent operative intervention indicated Death Definition: A finding of leakage resulting from breakdown of a vaginal anastomosis (surgical connection of two separate anatomic structures). Vas deferens anastomotic leak Asymptomatic diagnostic observations only; intervention not indicated Symptomatic; medical intervention indicated Severe symptoms; radiologic, endoscopic, or elective operative intervention indicated Life-threatening consequences; urgent operative intervention indicated Death Definition: A finding of leakage resulting from breakdown of a vas deferens anastomosis (surgical connection of two separate anatomic structures). Venous injury Asymptomatic diagnostic finding; intervention not indicated Symptomatic. Wound complication Incisional separation of 25% of wound, no deeper than superficial fascia Incisional separation >25% of wound; local care indicated Hernia without evidence of strangulation; fascial disruption/dehiscence; primary wound closure or revision by operative intervention indicated Hernia with evidence of strangulation; major reconstruction flap, grafting, resection, or amputation indicated Death Definition: A finding of development of a new problem at the site of an existing wound.
The safety of unilateral salpingectomy or salpingo-oophorectomy in appropriately staged young patients who desire fertility and whose disease apparently is confined to one tube has not been established acne hyperpigmentation 30 mg procuta amex. Removal of the remaining tube and ovary (or ovaries) should be performed at the completion of childbearing acne jeans shop purchase 40 mg procuta free shipping. Peritoneal cytologic specimens should be obtained on opening the peritoneal cavity acne in your 30s purchase genuine procuta on-line, not only from the pelvis acne nodule order procuta 40mg on line, but also from the lateral paracolic gutters and supradiaphragmatic areas. Prognostic correlation with peritoneal cytologic findings has been noted in a report from the Mayo Clinic. Patients with negative cytologic findings had a 5-year survival of 67% compared with 20% in patients with positive cytologic findings. Any disease outside the areas already extirpated should be removed if technically feasible. Debulking, as described in ovarian carcinoma, would also be applicable to this malignancy. Carcinomatous reduction to 1 cm or smaller was feasible in two thirds of patients reported by Podratz and colleagues. Patients with an earlier stage and complete surgical removal have a better survival than do patients with advanced disease and suboptimal removal. Pelvic and para-aortic lymph node sampling (above the inferior mesenteric artery) are required for staging, even for patients with apparent early-stage disease, because of the risk of early lymphatic spread. Of patients subjected to routine lymphadenectomy, 42% to 59% will show metastatic disease, a rate higher than that seen with ovarian cancer. Even in apparent early-stage disease, the propensity for retroperitoneal nodal spread is high. The therapeutic value of systematic complete lymphadenectomy remains controversial with a paucity of clinical data to support its use. Growth is limited to one tube, with extension into the submucosa or muscularis but not penetrating the serosal surface; no ascites. Growth is limited to both tubes, with extension into the submucosa or muscularis but not penetrating the serosal surface; no ascites. Tumor stage Ia or Ib but with tumor extension through or on to the tubal serosa; or with ascites present containing malignant cells, or with positive peritoneal washings. Tumor involves one or both fallopian tubes, with peritoneal implants outside the pelvis or positive retroperitoneal or inguinal nodes. Tumor appears limited to the true pelvis but with histologically proven malignant extension to the small bowel or omentum. Tumor is grossly limited to the true pelvis, with negative nodes but with histologically confirmed microscopic seeding of abdominal peritoneal surfaces. Tumor involving one or both tubes, with histologically confirmed implants of abdominal peritoneal surfaces, none exceeding 2 cm in diameter. Abdominal implants >2 cm in diameter or positive retroperitoneal or inguinal nodes. Alvarado-Cabrera et al have proposed that stage I disease be further subdivided based on no extension (0), extension into the lamina propria (1), and extension into the muscularis (2), with disease of the fimbria designated as a separate substage, 1(f). Patients with stage Ia tumor without spread to the muscularis layer had 100% 5-year survival in the report by Alvarado-Cabrera and colleagues and need not be treated. In contrast, patients with invasion of the muscularis layer or tumor in the fimbria, who had a 5-year survival of 71% to 72%, should receive additional therapy. Historically, the use of alkylating agent chemotherapy did not improve survival in this group of patients. Five of eight patients with suboptimal cytoreduction at the time of laparotomy developed recurrence, and four were re-treated with the same combination. In an earlier report by Barakat and colleagues, 38 patients were treated with cisplatin-based combination chemotherapy, with an overall survival of 51% at 5 years. It appears that cisplatinbased chemotherapy improves long-term survival in patients with advanced disease, but it may not be as effective as platinum combined with paclitaxel. This conclusion has been supported recently by Leath and colleagues, who reported in their series of 38 patients that those treated with paclitaxel and platinum had superior overall survival compared to those patients treated with cisplatin alone or melphalan. Recently, Pectasides and colleagues reported a retrospective analysis of 64 patients treated in contemporary practice with carboplatin and paclitaxel. Among patients with measurable disease, they reported a 68% complete response and 25% partial response rates. In this study, stage and residual disease were prognostic for both overall survival and for time to progression. These patients also had a significantly better 5-year survival rate (83%) than did those with gross residual disease (28%). Much of the data regarding radiation therapy precede the era of surgical staging of apparent earlystage disease, making it difficult to draw conclusions regarding efficacy in properly staged patients. They found significantly improved survival in patients undergoing surgery that included lymphadenectomy, presumably as a result of exclusion of advanced-stage disease in this group. Prognosis Survival with fallopian tube carcinoma has traditionally been reported as poorer than for ovarian cancer, but this has changed in two recent reports (Table 13-4). Survival may improve further as a larger proportion of patients is staged and treated appropriately. Compared to ovarian cancer patients, those with fallopian tube carcinoma were more likely to present with earlier stage tumors. Other recent large retrospective reviews report worse survival for patients with early-stage disease, but these studies cover many years, with a large percentage of patients not receiving adequate staging or platinum and paclitaxel therapy. The wide disparity in reported results from these and other studies are explained in part by inherent biases present in retrospective reviews, lack of uniformed and consistent staging likely resulting in stage migration, inconsistent adjuvant chemotherapy and/or radiation use, nonstandardized chemotherapy regimens used, and lack of central pathology review. Stage and the amount of residual disease at the time of debulking have consistently been found to be important prognostic factors, and some reports also have found age, grade, lymphovascular space involvement, and a closed fimbriated end of the fallopian tube to be significant.
Radiation therapy has been used concurrently with chemotherapy in an attempt to limit acute hemorrhagic complications from these metastases acne aid soap quality procuta 10mg. Brain irradiation combined with systemic chemotherapy is successful in controlling brain metastases acne vitamins procuta 20 mg line, with cure rates up to 75% in patients who initially present with brain metastases acne remedies proven procuta 40mg. However acne marks procuta 10 mg fast delivery, a similar primary remission rate has also been reported among patients treated with combination regimens that incorporated high-dose systemic methotrexate combined with intrathecal methotrexate infusions without brain irradiation. The best treatment for liver or other high-risk sites of metastases has not been established. Even with intense chemotherapy, additional surgery may be necessary to control hemorrhage from metastases, remove chemoresistant disease, or treat other complications to stabilize high-risk patients during therapy. Myelosuppression is more severe in patients receiving regimens for salvage than when they are used as primary therapy. Ifosfamide-containing chemotherapy produced responses in four of five patients reported by Sutton and colleagues, but only one patient 7. Surgery Brewer and associates reported that survival of patients treated with hysterectomy was only 40% for women with nonmetastatic choriocarcinoma and only 19% for those with metastatic choriocarcinoma before effective chemotherapy was developed. The majority of their patients died of progressive disease within 2 years of surgery. However, many procedures remain useful adjuncts when integrated into the management of these patients. Primary or delayed hysterectomy can be integrated into management to remove central disease, and surgical extirpation of metastases may cure highly selected patients with drug-resistant disease. At Duke University Medical Center, extirpative procedures such as hysterectomy were usually performed during a course of chemotherapy to minimize the possibility of inducing metastases by surgical manipulation of tissues. There did not appear to be an increase in surgical morbidity using this combined modality approach. Surgical procedures are often required during therapy of patients with high-risk disease to treat complications of the disease, such as hemorrhage or abscess, and allow stabilization during chemotherapy. Percutaneous angiographic embolization can allow relatively noninvasive control of hemorrhagic complications of pelvic tumors or metastatic lesions. Furthermore, the majority can be cured with chemotherapy alone, especially women with nonmetastatic or low-risk metastatic disease. Of these, 162 wished to retain childbearing capacity and 89% were able to avoid hysterectomy. All 32 women treated with primary hysterectomy combined with methotrexate or actinomycin-D single-agent chemotherapy regimens entered sustained remission. When compared to similar patients who had low-risk disease and were treated with chemotherapy alone, patients receiving primary hysterectomy had shorter duration of chemotherapy and lower total dosage of chemotherapy, roughly equivalent to one cycle of chemotherapy. They found that the total dosage of etoposide was decreased in women with nonmetastatic disease treated with adjuvant hysterectomy compared to those who were treated with chemotherapy alone, again roughly equivalent to a single cycle of chemotherapy. This effect was not observed among their patients with low-risk metastatic disease, where similar total dosages of etoposide were given to patients treated with adjuvant hysterectomy or chemotherapy alone. Therefore, the major role of primary hysterectomy should be as part of primary treatment for women with nonmetastatic disease or with limited 212 7. Delayed hysterectomy is often considered for patients who fail to respond to primary chemotherapy. Others have reported that salvage hysterectomy is effective in producing remissions in most patients with nonmetastatic or low-risk metastatic disease. Control of extrauterine disease is central in the success of salvage hysterectomy for these patients. The majority of these patients had no radiographic evidence of extrauterine disease, and 10 (83%) had sustained remissions. All patients had lesions localized in the myometrium and defined by pelvic angiography, ultrasound, and computerized tomography techniques. Pregnancies have been documented after conservative resections of invasive moles; Kanazawa and colleagues observed that reproductive performance was similar to that of patients treated with chemotherapy alone. Because of the high cure rates reported following chemotherapy alone in similar patients, it is more rational to consider these as salvage procedures in women with localized chemoresistant disease. Although this can safely be performed in conjunction with chemotherapy, it is not necessary to resect lung metastases in the majority of patients. As in the case of brain, liver, or renal metastases, any woman of reproductive age who presents with an apparent metastatic malignancy of unknown primary site should be 7. Resection of pulmonary nodules in highly selected patients with drug-resistant disease may successfully induce remission. Immediately before performing pulmonary resection, it is important to exclude the possibility of active disease elsewhere by performing a comprehensive metastatic survey. Highly selected patients will require more than one pulmonary resection during the course of treatment in order to achieve a durable remission. However, Rustin and colleagues recommended an approach using early craniotomy with excision of isolated lesions combined with high-dose systemic and intrathecal chemotherapy to treat patients with brain metastases. Both primary radiation therapy combined with chemotherapy and the approach emphasizing early surgical intervention appear to have similar efficacy in previously untreated patients. She is in remission following surgical resection of this brain lesion during her first cycle of chemotherapy followed by multiple cycles of chemotherapy with high-dose methotrexate combinations, platin-taxane, and hysterectomy.
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Following this report skin care brands 30mg procuta sale, several small series of laparoscopic staging in this patient population have been published skin care lounge purchase 40 mg procuta fast delivery. In a casecontrolled series acne scars 30 mg procuta mastercard, Chi demonstrated equivalent node counts and omental size removed in patients undergoing laparoscopic versus open procedures acne en la espalda discount 10 mg procuta fast delivery. There was no significant difference in rate of metastatic disease between the groups, although the numbers are too small to provide adequate power. Leblanc has recently reported on 42 patients who underwent laparoscopic restaging for ovarian and fallopian tube cancers. There were three reported recurrences in this group with a median follow-up of 54 months. To date there are no randomized trials looking at surgical staging or survival outcomes in early-stage ovarian cancer managed laparoscopically. Authors have reported its use in confirming the origin of abdominal carcinomatosis prior to neoadjuvant chemotherapy. Initial studies from the early 1980s utilizing laparoscopy followed by immediate laparotomy indicated a false-negative predictive value of 29% to 55% for laparoscopic surgery. With advances in video equipment and surgical technology there has been a resurgence of use of laparoscopic surgery in this setting. In more recent nonrandomized trials reporting on technical feasibility it appears laparoscopy is comparable to laparotomy in terms of complications, with a range of 1% to 5%. Unfortunately these studies were not controlled with immediate postlaparoscopy laparotomy, so the false-negative rate cannot be adequately assessed. Clough did report on 20 patients undergoing initial laparoscopy followed by immediate laparotomy using modern minimally invasive technology. The negative predictive value was 86%, indicating continued deficiencies in the technique. This information, in combination with the fact that second-look surgery has been determined to be of no therapeutic value, relegates this surgery to limited application in the setting of research protocols. Some investigators have recently reported on the use of hand-assisted laparoscopy for radical intraperitoneal tumor debulking and cytoreductive surgery. These studies lack conclusive data for adequacy of surgery or comparison with open technique for morbidity and survival and should be considered investigational. Laparoscopy can be useful for determining extent of disease in order to assess the feasibility of cytoreductive surgery or neoadjuvant chemotherapy. Ports for intraperitoneal chemotherapy can be placed with laparoscopic guidance in patients without such access before initiating primary chemotherapy. Many complications related to the specific surgical procedures will occur at least at a minimum rate and can vary with complexity of the procedure and surgeon experience. Approximately 50% of serious intraoperative complications in laparoscopy occur with trochar insertion. In general gynecology major vascular injuries are almost exclusively related to trochar insertion; however, in gynecologic oncology such injuries may also occur during retroperitoneal dissection. There should be a high index of suspicion and the expectation should be continuous improvement postoperatively. Genitourinary complications are prevented by meticulous dissection, wide mobilization of the bladder off of the lower uterine segment and cervix, and skeletonization of the uterine vessels. As noted previously in this chapter, a number of studies have reported on complications associated with laparoscopic pelvic and para-aortic lymphadenectomy and radical pelvic dissection. In early series there appeared to be an increased number of ureteral, bladder, and vascular injuries compared to open technique. Prevention of complications begins long before the actual operative procedure with appropriate treatment selection and preoperative counseling. Chi reported on the risk factors for complications and conversion to laparotomy in 1451 patients undergoing a wide variety of laparoscopic procedures by a gynecologic oncology division over a 10-year time frame. The complication rates reported in this series fall within the accepted range using an open technique. Likewise, the need to convert to laparotomy has been associated with prior abdominal surgeries, obesity, bleeding, and adhesive disease. Conversion rates decrease with increased surgeon experience and should not be considered a complication but rather sound intraoperative judgment. There is no substitute for continued practice and accumulated experience, which allows for development of innate skills in avoiding potential problems. Meticulous skeletonization of pedicles and mobilization of adjacent structures away from the field of dissection reduce the chance of unintended thermal damage. Laparoscopy gives partial loss of haptic feedback and loss of three-dimensional vision, whereas the current robotic technology gives no haptic or touch feedback but allows for high-definition three-dimensional vision. Both limitations in sensory feedback can be overcome with practice and experience while maintaining rigorous surgical discipline. Port-Site Recurrences Since 1978 port-site recurrences have been reported in multiple carcinomas, including gynecologic malignancies. Concern has been expressed that incisional seeding may be increased in laparoscopic surgery potentially leading to a reduction in overall survival. A review of the literature by Ramirez in 2003 found 31 articles describing port-site metastases in 58 gynecologic cancer patients. These included 33 invasive ovarian cancers, 7 low malignant potential tumors of the ovary, 12 cervical cancers, 4 endometrial cancers, and 1 each of fallopian tube and vaginal cancer. In the ovarian cancer patients, 83% had advanced-stage disease with most reporting carcinomatosis and ascites. The median time to diagnosis was 17 days, and it is unclear how this affected survival. Reports of abdominal wall metastasis after paracentesis in a similar population are common. The 12 cervical cancer patients reported with port-site metastasis are cause for concern given that there are only a few isolated reports of metastases to an abdominal scar.
