Evaluation of laparoscopic and robotic sacrocolpopexy with total hysterectomy using the POP-Q system and EQ-5D

　背景：超高齢社会の到来で，QOL を損なう骨盤臓器脱に対する手術療法は増加し，当院でも腹腔鏡・ロボット仙骨腟メッシュ固定術（LSC･RSC）を行っている．子宮の取り扱いは施設によって異なり，子宮温存，子宮亜全摘，子宮全摘術のいずれかを併用する．子宮全摘を併用した場合，メッシュびらんの頻度が増加するという報告があり，メッシュびらんを予防する目的で子宮頚部を残す腟上部切断術が主流である．しかし，悪性病変の発生リスクを低減するために，当院では子宮全摘を伴う LSC･RSC を施行している．これまで子宮全摘を伴う LSC･RSC に限定して POP-Q スコアや QOL を評価した報告はない．今回，子宮全摘を伴う LSC･RSC での術前術後の骨盤臓器脱の構造的な評価方法である POP-Q システムによるスコアリングと QOL の評価方法である EQ-5Dを用いて，当院で行っている LSC・RSC の有効性，患者満足度を検討した．　方法：2020年４月より１年間，骨盤臓器脱の患者に同意を得て，手術前後で POP-Q システムの記録と EQ-5D による質問を実施し，POP-Q システムのスコア，stage と EQ-5D の関係や手術前後の評価を行った．　結果：症例は合計22例で，術式は LSC と RSC によるものが各11例であった．全体の手術成績平均は，手術時間148分，出血量30 ml，摘出子宮54 g だった．全体のPOP-Q stage は，術前平均2.45，術後平均0.41で，有意に改善を認めた（ｐ ＜ 0.001）．全体の EQ-5D のスコアは，術前0.719，術後0.991で有意に改善を認めた（ｐ ＜ 0.001）．また2022年３月までの観察期間中，再発やメッシュびらんを認めた症例はなかった．子宮全摘を併用した LSC･RSC は，腹腔鏡とロボットのいずれにおいても QOL を改善した．短期から中期の観察ではあるが再発やメッシュびらんを認めなかった．子宮全摘を併用した LSC･RSC は，仙骨腟メッシュ固定術の一つの選択肢となり得ると考えられた．　Background: The advent of a rapidly aging society has increased the number of surgeries for pelvic organ prolapse (POP), thus affecting quality of life (QoL). At our hospital, laparoscopic and robotic sacrocolpopexy (LSC and RSC) has been performed for mesh insertion. Different institutions handle the uterus by conserving it either via subtotal hysterectomy, or total hysterectomy. The frequency of mesh erosion increases with total hysterectomy. Supra hysterectomy, which preserves the cervix, is the mainstream method for prevention of mesh erosion. However, at our hospital, LSC/RSC with total hysterectomy is used to reduce the risk of malignant lesions. There are no reports of POP-Q scores or QoL evaluated only in patients who underwent LSC/RSC with total hysterectomy. This study aimed to examine the efficacy and patient satisfaction of LSC/RSC performed at our hospital. We used the POP-Q system, a structural assessment, and the QoL assessment EuroQoL-5D (EQ-5D) before and after POP surgery with LSC/RSC and total hysterectomy.　Methods: In the 1 year from April 2020, consenting patients with POP were evaluated using the POP-Q system and EQ-5D before and after surgery. We determined the relationships among the POP-Q system scores, stage, and EQ-5D scores and compared them before and after surgery.　Results: Of the 22 patients, LSC or RSC was performed in 11 patients each. The overall mean surgical outcomes comprised surgery duration (148 min), bleeding volume (30 ml), and weight of the removed uterus (54 g). The mean overall POP-Q stage and overall EQ-5D score improved significantly (p < 0.001) from 2.45 and 0.719 preoperatively to 0.41 and 0.991 postoperatively, respectively. Furthermore, no cases of recurrence or mesh erosion were noted during follow-up to March 2022. LSC/RSC with total hysterectomy improved the QoL in both laparoscopic and robotic cases. No cases of recurrence or mesh erosion were noted in the short- to mid-term follow-up. Surgeons can consider LSC/RSC with total hysterectomy as an option for mesh insertion

腹腔鏡検査にて確定診断に至った結核性腹膜炎の一例

　症例は63歳女性．元医療従事者であった．１ヵ月続く腹痛と38度の発熱で近医を受診し，腹水貯留を認め，腹水検査でヒアルロン酸とCA125が高値であったことから癌性腹膜炎を疑われ当院内科に紹介された．画像検査より癌性腹膜炎を疑われたが，原発は同定できなかった．細胞診はclassII であったが，卵巣癌，腹膜癌，悪性中脾腫を疑われたことから，腹腔鏡検査目的に当科紹介となった．腹腔鏡検査で黄白色粒状の病変を認め，病理組織検査にて類上皮細胞性肉芽腫を認め，結核等の感染症が疑われた．病歴聴取にて３年前の職務中に結核排菌患者に濃厚接触歴あり，腹腔鏡再検査にて，塗抹，培養，PCR 陰性であったが，腹水中ADA 高値より結核と診断し結核専門病院に転院した．抗結核薬開始され速やかに症状は軽快した．結核性腹膜炎は非常に稀な疾患であるが，腹腔鏡検査で診断に至った症例を経験した．原因不明腹水を認めた場合，癌性腹膜炎のみならず感染性腹膜炎の可能性も念頭に置き早期から同時に精査する必要がある．　A 63-year-old woman, who was a former healthcare professional, visited a nearby clinic for headache and a fever of 38℃ that had lasted for a month. Ascites was observed, and ascitic fluid examination showed high hyaluronan and CA125 levels, suggesting cancerous peritonitis. She was referred to the internal medicine department at our institution. Although the primary site was not identified, imaging findings suggested cancerous peritonitis. Cytology showed class II features, with the possibility of ovarian cancer, peritoneal cancer, or malignant mesothelioma. She was referred to our department for laparoscopic examination, which showed epithelioid cell granulomas, suggesting an infectious disease, which could include tuberculosis. History taking revealed close contact with a tuberculosis-shedding patient at work 3 year ago. Although the smear, culture, and polymerase chain reaction tests were negative, on laparoscopic reexamination, tuberculosis was diagnosed because of elevated adenosine deaminase in the ascitic fluid. She was transferred to a tuberculosis specialty hospital;antituberculosis therapy was started, and the symptoms quickly resolved. We experienced a very rare case of tuberculous peritonitis, diagnosed laparoscopically. Ascites from an unknown cause requires close examination for not only cancerous peritonitis but also infectious peritonitis

Postoperative nausea and vomiting in benign gynecological laparoscopic surgery when acetaminophen is combined with non-opioid analgesic management

　Non-opioid analgesic management using intravenous acetaminophen has been reported to reduce pain and postoperative nausea and vomiting (PONV). This study aimed to assess the incidence rate and risk factors for PONV following benign gynecological laparoscopic surgery with non-opioid analgesic management, when using intravenous acetaminophen to achieve appropriate perioperative management. We conducted a retrospective observational study comprising 53 patients who underwent five types of laparoscopic surgical procedures for benign diseases. The patients were administered a single dose of intravenous acetaminophen at the conclusion of the operation, after which pain relief was induced with non-steroidal anti-inflammatory drugs and pentazocine. We analyzed patient characteristics, surgical outcomes, and numbers of analgesics and antiemetics administered postoperatively. Onset of PONV developed by postoperative day one. The incidence rate of PONV in patients who underwent surgery that included total hysterectomy was 94%, which was significantly higher than in those who underwent other procedures ( p = 0.020). From the perspective of PONV, current postoperative pain management for laparoscopic surgery, including total hysterectomy, needs to be modified

Laparoscopic Adenomyomectomy under Real-Time Intraoperative Ultrasound Elastography Guidance: A Case Series and Feasibility Study

Background: This study aimed to examine the clinical characteristics of 11 patients undergoing laparoscopic adenomyomectomy guided by intraoperative ultrasound elastography and this technique&rsquo;s feasibility. Patients and Methods: Eleven patients undergoing laparoscopic adenomyomectomy using ultrasound elastography for adenomyosis at Kawasaki Medical School Hospital in Okayama, Japan between March 2020 and February 2021 were enrolled. Operative outcomes included operative time, operative bleeding, resected weight, operation complications, percent change in hemoglobin (Hb) values, and uterine volume pre- and postoperatively. Dysmenorrhea improvement was evaluated by changes in visual analog scale (VAS) scores pre- and 6- and 12-months postoperatively. Results: The median operative time and bleeding volume was 125 min (range, 88&ndash;188 min) and 150 mL (10&ndash;450 mL), respectively. The median resected weight was 5.0 g (1.5&ndash;180 g). No intraoperative or postoperative blood transfusions or perioperative complications were observed. The median changes in uterine volume, Hb value, and VAS score were &minus;49% (&minus;65 to &minus;28%), &minus;3% (&minus;11 to 35%), and &minus;80% (&minus;100 to &minus;50%), respectively. The median follow-up period post-surgery was 14 months (7&ndash;30 months). Adenomyosis recurrence was not observed in the patients during the follow-up period. Conclusions: Laparoscopic adenomyomectomy using ultrasound elastography guidance is minimally invasive and resects as many adenomyotic lesions as possible

Does local infiltration anesthesia on laparoscopic surgical wounds reduce postoperative pain? Randomized control study

Abstract Purpose Recently, endoscopic surgeries are widely performed in the gynecological field. Several studies on the use of local anesthesia for pain control after laparoscopic surgery have been conducted; however, its effects remain controversial. Herein, a randomized control study on gynecological laparoscopic surgeries was conducted to analyze the effectiveness of local anesthesia on postoperative pain. Methods Patients who underwent laparoscopic surgeries due to gynecologic benign diseases or endometrial cancer in the early stage were enrolled, and randomly divided into intervention (injected with levobupivacaine), and control (injected with saline) groups. The primary outcome was the dosage of analgesic consumption within 12 hours postoperatively. Results A total of 147 patients were enrolled in the intervention group and 147 in the control group. The outcome of local anesthesia was not significantly different between the two groups during the whole analysis. We analyzed the effects of local anesthesia in the laparoscopic surgery subgroup. The dosage of analgesic consumption within 12 h after a laparoscopic hysterectomy (TLH) or TLH with pelvic lymph node dissection (TLH+PLD) in the intervention group was significantly smaller than that in the control group. Conclusion Local infiltration anesthesia can effectively reduce postoperative pain in patients who underwent TLH or TLH +PLD

POP-Q システムと EQ-5D を用いた子宮全摘を伴う腹腔鏡・ロボット仙骨腟メッシュ固定術の評価

原著論文Regular Articlejournal articl