The patient described provided written informed consent for the use and publication of medical data, operative video, and related images for educational and scientific purposes. The following protocol adheres to the human research ethics committee guidelines of Montefiore Medical Center and New York City Health and Hospitals Corporation.
Due to limitations of the available raw recording, not every step in the protocol could be fully documented in the video on this patient.
1. Preoperative evaluation
NOTE: Select patients who are candidates for a minimally invasive surgical resection. Preoperative evaluation is important to create a comprehensive surgical plan and facilitate a thorough informed consent discussion to delineate indications for, risks of, benefits and alternatives to surgical management.
<ol>
	<li>Obtain a thorough history.</li>
	<li>Perform an abdominal and pelvic exam.</li>
	<li>Screen the patient for features of malignancy or deep-infiltrating endometriosis (DIE), which may require pre-surgical coordination with other specialists such as colorectal, urological surgeons, or gynecologic oncologists.
	<ol>
		<li>Obtain abdominal-pelvic imaging with transvaginal ultrasonography (TVUS). Transvaginal ultrasonography is a standard imaging modality as it usually provides adequate visualization and enhanced resolution of the uterus, posterior cul-de-sac, right adnexa, and left adnexa.</li>
		<li>Consider obtaining magnetic resonance imaging (MRI) as shown in Figure 1 to evaluate for the presence of adnexal pathology, adenomyosis, hydronephrosis, and evidence of deeply infiltrating endometriosis (DIE). These findings may be reliably assessed by ultrasound when the study is performed with bowel preparation by an experienced radiologist. 
		NOTE: Hysterosalpingogram (HSG) may be performed to assess for tubal patency.</li>
	</ol>
	</li>
	<li>Determine whether the patient is an appropriate surgical candidate. Indications for surgical cystectomy include size greater than 4 cm with pain or infertility, or size less than 4 cm with medically refractory pain or concern for follicle count or accessibility during assisted reproduction. 
	NOTE: Tailor the approach to the patient&#39;s goals and preferences. Determine whether the patient desires complete removal of endometriosis or prefers more limited surgery. Consider post-surgical fertility plans and whether bilateral or unilateral adnexal resection is indicated. Incomplete resection of disease increases the risk of recurrence but may allow for shorter surgery and reduced morbidity and complications.</li>
	<li>Complete an informed consent discussion to discuss potential risks and benefits of the proposed surgery. Ensure that the patient has no other contraindications. 
	&#8203;NOTE: A more complete resection of ovarian disease often risks decline in ovarian reserve. The patient should be informed of management options regarding abnormal salpinges. In cases of deep infiltrating endometriosis, significant surgical morbidity and need for bowel resection must be addressed. Surgeons must discuss probable events and possible procedure-related complications, including bowel injuries, bleeding, genital-tract injuries, urologic injuries, return of pelvic pain, and post-operative infection.</li>
</ol>
2. Exam under anesthesia and diagnostic laparoscopy
NOTE: The preoperative evaluation and exam under anesthesia are crucial to safely entering the peritoneum and guide the diagnostic laparoscopy.
<ol>
	<li>Position the anesthetized patient in dorsal lithotomy position. The arms should be tucked in a neutral anatomical orientation and care should be taken to protect neurovascular areas.</li>
	<li>Perform an exam under anesthesia. Evaluate for the presence of abdominal wall hernias and scars to guide trocar placement, the size and position of pelvic organs, and for the presence of nodularity in rectovaginal septum as well as other possible sites of endometriosis not appreciated during prior pelvic exam.</li>
	<li>Prepare the surgical site.
	<ol>
		<li>Use appropriate agents (chlorhexidine gluconate in isopropyl alcohol for skin, povidone-iodine or chlorhexidine gluconate for the vagina) and allow the skin to dry. Cover the patient with sterile drapes.</li>
		<li>Place a urinary Foley catheter in the bladder for urine output monitoring and bladder decompression.</li>
	</ol>
	</li>
	<li>Create pneumoperitoneum using standard techniques with entry either peri-umbilically or at Palmer&#39;s Point (Figure 2). 
	NOTE: Use the smallest required trocars and the lowest insufflation pressures to decrease postoperative pain and facilitate patient ventilation.</li>
	<li>Place at least two additional lower abdominal ports as shown in Figure 2.</li>
	<li>Perform a diagnostic laparoscopy to exclude surgical injury during entry and to identify anatomy, adhesions and possible endometriotic implants in the peritoneal cavity (upper and lower abdomen). Evaluate for avascular sites free of adhesions for accessory port placement. 
	NOTE: Port placement should facilitate ergonomics and allow for full visualization and manipulation of pelvic tissue.</li>
	<li>Complete diagnostic laparoscopy. 
	NOTE: A combined approach with adhesiolysis (see steps 3.1-3.4) may be required to completely evaluate the pelvis. The surgeon may choose to defer complete adhesiolysis when balancing its higher surgical risk with the benefits of comprehensive pelvic assessment.
	<ol>
		<li>Place a uterine manipulator (see Table of Materials) and utilize a steep Trendelenburg position to optimize visualization of pelvic structures.</li>
		<li>Sweep mobile structures out of the pelvis with atraumatic graspers.</li>
	</ol>
	</li>
	<li>Systematically evaluate all pelvic structures and spaces. Biopsy any possible endometriotic lesions for diagnostic purposes. 
	NOTE: Endometriosis typically appears as red or white lesions; however, its appearance may be highly variable.
	<ol>
		<li>Use a 30&#176; laparoscope to aid visualization around structures, as needed.</li>
		<li>Obtain pelvic washings of free peritoneal fluid.</li>
	</ol>
	</li>
	<li>Score the extent of pelvic disease using a validated system. 
	&#8203;NOTE: The revised American Society for Reproductive Medicine (rASRM) system21 is most commonly used. However, the Endometriosis Fertility Index (EFI)22 is most appropriate for predicting fertility outcomes.</li>
</ol>
3. Lysis of adhesions
NOTE: This phase is critical for the exposure, restoration of neutral anatomical position, and subsequent enhancement of genital tract function. Ovarian adhesions may prevent follicular development and extrusion of a ruptured follicle with ovulation, while fimbrial adhesions may compromise sweeping of an ovum. Additionally, adequate adhesiolysis is crucial to assure tubal patency. Adhesions are created by inflammatory states, whether by prior surgeries, infection, or endometriosis. Adhesions interfere with adequate exposure, distort anatomy, and subsequently increase complication risk when handling tissue and attempting plane development. Due to distorted anatomical planes, major pelvic vessels and the ureter are frequently in close proximity to the sites of dissection. The surgeon must be prepared to perform retroperitoneal dissection and ureterolysis for safe identification of anatomy.
<ol>
	<li>Consider placement of additional ports at this time, as it will allow for more instruments to work in tandem along with the laparoscope.</li>
	<li>Once port placement is optimal, dissect adhesions to expose the adnexa. Divide &#34;kissing&#34; ovaries and lyse tubal adhesions to free the length of the entire salpinges, including fimbriae.
	<ol>
		<li>Start with the blunt dissection from the healthy tissue proximally, working towards dense adhesions and abnormal anatomy. Triangulate applied forces to allow for efficient dissection. 
		NOTE: Blunt dissection is not always possible with dense adhesions. It is best to start with filmy adhesions to mobilize pelvic and vascular structures to facilitate plane development between adherent structures which may require sharp dissection. The suction irrigator can bluntly dissect, push, sweep, hydrodissect, and aspirate from the surgical field without instrument exchanges. Use atraumatic graspers to apply traction to sensitive tissue and to push and spread.</li>
		<li>Continue along a dissection plane until it can no longer be easily developed bluntly, with care to avoid excessive force. Use scissors or energy devices with minimal lateral thermal spread such as ultrasonic shears to dissect dense adhesions, as these instruments minimize potential for inadvertent injury.</li>
		<li>Focused electrosurgery may be required to control bleeding.</li>
	</ol>
	</li>
	<li>Free the ovary from adjacent structures, such as the pelvic sidewall and cul-de-sac. Ensure full tubal length is freed from adhesions including fimbriae. 
	NOTE: The ovary is often encased in adhesions, which may prevent ovum capture by the salpinges following ovulation.</li>
	<li>Perform retroperitoneal dissection and ureterolysis for safe identification of anatomy prior to dividing adherent structures. 
	&#8203;NOTE: This step ensures that the ureter is not inadvertently damaged. The retroperitoneum is best opened starting at a site of normal anatomy adjacent to the endometriosis and is commonly entered at the level of the pelvic brim by the pelvic sidewall.</li>
</ol>
4. Chromopertubation
<ol>
	<li>Inject dilute methylene blue (Table of Materials) through the uterine manipulator.</li>
	<li>Evaluate laparoscopically for the distension of the fallopian tube and spillage of dye from the fimbriae (Figure 4). If tubal patency is not demonstrated and the fimbriated end appears irreparable, then perform salpingectomy.</li>
	<li>If tubal patency is not demonstrated, perform the following steps.
	<ol>
		<li>Ensure adequate fimbriolysis.</li>
		<li>Use atraumatic graspers to occlude the patent tube proximally. 
		NOTE: Dye will most readily pass through the side with lower occlusion pressure. Use graspers to transiently occlude one&#160;patient side and favor passage of dye through the other.</li>
		<li>Replace the uterine manipulator with a dedicated catheter for HSG and re-attempt distension.</li>
	</ol>
	</li>
</ol>
5. Address tubal pathology
NOTE: Features of abnormal salpinges include irregular contours from adhesions or contents of hydro-, hemato-, or pyosalpinx. Salpinges are also pathologic if chromopertubation fails to demonstrate patency following adequate adhesiolysis. Abnormal salpinges are associated with poor spontaneous pregnancy rates and risk for ectopic pregnancy. Additionally, retrograde flow of tubal contents may reduce implantation rates. Bilateral salpingectomy or occlusion will necessitate in vitro fertilization for future fertility and must be explicitly defined in the surgical plan. Consider salpingectomy for irreparable salpinges when&#160;access to salpinges and mesosalpinx is feasible. Proximal tubal ligation to occlude retrograde flow of dilated tubal contents into the endometrial cavity is an acceptable alternative. Proximally occluded tubes may be left in situ.
<ol>
	<li>Identify the fallopian tube and the infundibulopelvic ligament.</li>
	<li>Expose and elevate the tube with graspers. 
	NOTE: The fimbriated ends should be maintained far from the ovary and the pelvic sidewall to avoid damage from inadvertent lateral thermal spread to either structure.</li>
	<li>Start the dissection of the tubal lumen from the mesosalpinx at the fimbriated end. Avoid infundibulopelvic ligament ligation and limit the amount of mesosalpinx excised to avoid damage to the anastomotic vascular connections that support ovarian blood supply. 
	NOTE: Preserve ovarian blood supply. These vascular sites may be of potential importance for maintaining ovarian reserve.</li>
	<li>Reaching the isthmus, transect across the full tubal lumen to complete the salpingectomy. 
	NOTE: The patient should be informed of her tubal status and the presence of any remaining tubal tissue after surgery as it may affect her risk of malignancy.</li>
	<li>Ensure adequate hemostasis.</li>
	<li>Perform on the contralateral side, if applicable.</li>
	<li>Remove specimens through the trocar or in a containment device.</li>
</ol>
6. Ovarian endometrioma cystectomy
NOTE: Cystectomy offers the lowest rate of endometrioma recurrence and has been demonstrated to improve pain outcomes and spontaneous pregnancy outcomes; however, it also removes more normal ovarian tissue than ablation (e.g., with CO2 laser). Endometrioma cyst walls are usually adherent from fibrosis and vascular at their base. The surgeon must balance removal of normal ovarian parenchyma and hemostasis with preservation of normal ovarian tissue. Cystectomy should only be attempted if the patient will be expected to have adequate ovarian reserve following the cystectomy. Removal of endometrioma in patients desiring fertility is generally restricted to lesions &#62;3 cm and only if removal improves accessibility of follicles or endometriosis-associated pain.
<ol>
	<li>Identify the ovary. Divide the remaining adhesions to allow to free the ovary. Elevate the structure with graspers to facilitate exposure of the cyst wall. 
	NOTE: Any disruption of the endometrioma cyst wall will yield chocolate-colored fluid.</li>
	<li>Elevate the ovary with graspers to facilitate the exposure of the lesion. Incise the thinnest portion of ovarian cortex to expose the endometrioma cyst wall (Figure 5). 
	NOTE: This incision is ideally made over the thinnest area of the endometrioma surface or at the antimesenteric border of the ovary. Avoid multiple incisions in the ovarian cortex as this is the area where follicles are located. Alternative approaches to develop the cleavage plane include injection of dilute vasopressin or normal saline.</li>
	<li>Utilize traction-counter traction to separate the cyst wall from normal ovarian parenchyma. Dissect efficiently using close placement of graspers with applied force perpendicular to the dissecting plane. 
	NOTE: As the surgical plane develops, regrasp both the endometrioma cyst wall and the healthy ovarian tissue to ensure traction forces continue to be applied close to the site of dissection (Figure 5).</li>
	<li>After complete excision, assess the operative bed for hemostasis. 
	NOTE: As the dissection reaches the ovarian medulla near the end, it can be challenging to continue because of the presence of utero-ovarian vessels and potential for more brisk bleeding.
	<ol>
		<li>Use copious irrigation and aspiration to remove hemoperitoneum and evaluate for active bleeding. 
		NOTE: Consider dropping the insufflation pressure to ascertain hemostasis.</li>
		<li>Observe the ovary for 1-3 min as the endogenous coagulation cascade is activated.</li>
		<li>If bleeding continues, apply topical hemostatic agents. Such agents avoid the need for application of energy to ovarian tissue and the potential for damaging ovarian follicles. Consider laparoscopically suturing an actively bleeding vascular lesion.</li>
		<li>If conservative or medical application fails, apply focused ultrasonic energy once assured of a safe margin from genitourinary and gastrointestinal structures. 
		NOTE: Select an energy source with the least potential to cause ovarian damage by lateral thermal spread. Lateral thermal spread is lowest with laser vaporization, which has a minimal depth of penetration, followed by ultrasonic energy, followed by bipolar electrosurgery, while monopolar electrosurgical application has the greatest potential for lateral thermal spread and inadvertent injury to adjacent structures. Electrosurgery should be avoided adjacent to the bowel or ureters and judiciously minimized on the ovary.</li>
	</ol>
	</li>
	<li>Gather all specimens for retrieval into a bag to reduce risk of port-site endometriosis. Specimen removal should be under direct visualization.</li>
</ol>
7. Address the remaining sites of endometriosis per surgical plan
NOTE: Endometriosis outside of the ovary or tubes may have limited impact on spontaneous conception rate, but excision may be particularly important for treating pain or dysfunctional symptoms. Resection of implants should be site-directed. Peritoneal sites of endometriosis as well as other deep infiltrative sites should be addressed at this point. Retroperitoneal dissection is often required. Consider the morbidity of such procedures and patient goals when determining the necessity of such steps.
<ol>
	<li>Address peritoneal implants.
	<ol>
		<li>Select biopsy sites.</li>
		<li>Strip or ablate all visible peritoneal implants.
		<ol>
			<li>Use ultrasonic energy to divide the peritoneum adjacent to the implant.</li>
			<li>Mobilize tissue adjacent to implant. Remove implants en bloc.</li>
			<li>Remove endometriosis from the pelvic sidewall. This may require retroperitoneal dissection of the relevant avascular planes and identification of the branches of the internal iliac artery and the course of the ureter. 
			NOTE: Ureterolysis should be performed with blunt dissection using the push and spread technique to create a safe margin and preserve vascular supply to the ureter.</li>
		</ol>
		</li>
	</ol>
	</li>
	<li>Address deep infiltrating endometriosis (DIE) per the surgical plan. 
	&#8203;NOTE: Common sites of endometrial implants include the posterior-cul-de-sac and uterosacral ligaments. Removal of disease that cannot be shaved or safely ablated may require coordination with specialists such as urologic or colorectal surgeons.</li>
</ol>
8. Closure
<ol>
	<li>Confirm hemostasis at the operative bed.</li>
	<li>Close any fascial defects larger than 1 cm.</li>
	<li>Close the skin intracutaneously.</li>
</ol>

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(2), (2008).</li><li>Vignali, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgical+excision+of+ovarian+endometriomas:+Does+it+truly+impair+ovarian+reserve?+Long+term+anti-M&#252;llerian+hormone+(AMH)+changes+after+surgery.">Surgical excision of ovarian endometriomas: Does it truly impair ovarian reserve? Long term anti-M&#252;llerian hormone (AMH) changes after surgery.</a> Journal of Obstetrics and Gynaecology Research. 41 (11), 1773-1778 (2015).</li><li>Revised American Society for Reproductive Medicine. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Revised+American+Society+for+Reproductive+Medicine+classification+of+endometriosis.">Revised American Society for Reproductive Medicine classification of endometriosis.</a> Fertility and Sterility. 67 (5), 817-821 (1997).</li><li>Adamson, G. D., Pasta, D. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endometriosis+fertility+index:+the+new,+validated+endometriosis+staging+system.">Endometriosis fertility index: the new, validated endometriosis staging system.</a> Fertility and Sterility. 94 (5), 1609-1615 (2010).</li><li>Endometriosis and infertility Committee. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endometriosis+and+infertility:+A+committee+opinion.">Endometriosis and infertility: A committee opinion.</a> Fertility and Sterility. 98 (3), (2012).</li><li>Miller, C. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+endometrioma+treatment+paradigm+when+fertility+is+desired:+A+systematic+review.">The endometrioma treatment paradigm when fertility is desired: A systematic review.</a> Journal of Minimally Invasive Gynecology. 28 (3), 575-586 (2021).</li><li>Muzii, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Histologic+analysis+of+specimens+from+laparoscopic+endometrioma+excision+performed+by+different+surgeons:+Does+the+surgeon+matter.">Histologic analysis of specimens from laparoscopic endometrioma excision performed by different surgeons: Does the surgeon matter.</a> Fertility and Sterility. 95 (6), (2011).</li><li>Kotlyar, A., Gingold, J., Shue, S., Falcone, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+effect+of+salpingectomy+on+ovarian+function.">The effect of salpingectomy on ovarian function.</a> Journal of Minimally Invasive Gynecology. 24 (4), 563-578 (2017).</li></ol>

All the authors report no disclosures or conflicts of interest.

Patients with diagnosed endometriosis commonly report pain or implant-related organ dysfunction, including infertility. Up to 50% of patients with endometriosis meet criteria for infertility23. Ovarian reserve, measured via AMH levels, FSH levels around menses or an antral follicle count, is used to predict patient response to gonadotropin stimulation. Surgical management of endometrioma is known to decrease ovarian reserve23. However, ovarian reserve continues to decline i...

Endometriosis is a chronic inflammatory condition defined by ectopic endometrial tissue1. Patients with endometriosis commonly present with pain-related complaints and organ dysfunction related to the site of ectopic implantation, which may be anywhere in the body though is typically within the pelvis2,3. Ovarian endometrioma, in which a cyst of endometriosis forms within the ovary, contributes to subfertility by multiple means, including depletion of the ovarian follicle pool, promoting an inflammatory environment, progesterone resistance, and impaired ovum release and capture4. Affected patients frequently have diminished ovarian reserve upon presentation, and the follicle pool is further depleted following surgery5,6. Cyclic bleeding in sites with ectopic endometrial tissue leads to inflammation and significant adhesions, which may impair ovum pick-up and transport, fertilization, and embryo passage7,8,9. The abnormal inflammatory environment may also impair folliculogenesis and early embryonic development10,11.
At a practical surgical level, the resultant adhesions frequently obliterate normally avascular surgical planes, placing patients at elevated risk of prolonged operative times, blood loss, and surgical injury. Surgical management of patients desiring future fertility presents additional challenges, most notably risk of iatrogenic damage to the tubes and ovaries, compromising tubal patency or ovarian reserve12,13,14. However, surgical resection of endometriosis also presents a unique opportunity to potentially diagnose, evaluate, and treat identified lesions, including optimizing fertility15.
We detail our approach to the treatment of ovarian endometriomas in patients desiring future fertility. We strongly favor a laparoscopic approach over laparotomy for enhanced post-operative results, including less pain, shorter hospital stay, and quicker recovery16. This protocol prioritizes excision of ovarian endometrioma over drainage and ablation as it provides a more favorable outcome with respect to cyst recurrence, pain recurrence, and spontaneous pregnancies17,18,19,20. Additionally, it allows for the specimen retrieval for histology. We excise ovarian endometrioma via a stripping technique with limited electrosurgical energy application. Nonetheless, many specialized tools have been described for the management of ovarian endometrioma and multiple acceptable surgical approaches exist for patients desiring future fertility. Regardless of any specific technique employed, the considerations and surgical principles described in this protocol are applicable to all patients with endometriosis desiring fertility-optimizing surgery.
The protocol described below was employed for the care of a 32-year-old woman with chronic pelvic pain and histologically proven endometriosis identified during a prior laparoscopy, during which endometriosis was incompletely resected. She endorsed pain refractory to the first-line medical management and was interested in future fertility, although had not actively attempted spontaneous conception. She was deemed a candidate for minimally invasive surgical resection and underwent an exam under anesthesia, diagnostic laparoscopy, lysis of adhesions, ovarian cystectomy, chromopertubation, and salpingectomy. Her surgery and recovery were uncomplicated.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Basic laparoscopy</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>1L bag 0.9% NaCl solution</td>
			<td></td>
			<td></td>
			<td>Suction irrigation, hemostasis, lysis of adhesions</td>
		</tr>
		<tr>
			<td>1-10% povidone-iodine</td>
			<td></td>
			<td></td>
			<td>Sterile prep</td>
		</tr>
		<tr>
			<td>2% chlorhexidine gluconate in 70% isopropyl alcohol for skin</td>
			<td></td>
			<td></td>
			<td>Sterile prep</td>
		</tr>
		<tr>
			<td>4% chlorhexidine gluconate</td>
			<td></td>
			<td></td>
			<td>Sterile prep</td>
		</tr>
		<tr>
			<td>5mm laparoscopic trocar and sleeve x 3</td>
			<td>Covidien</td>
			<td>ONB5STF</td>
			<td>Diagnostic laparoscopy</td>
		</tr>
		<tr>
			<td>12mm laparoscopic trocar and sleeve</td>
			<td>Covidien</td>
			<td>ONB12STF</td>
			<td>Diagnostic laparoscopy and larger size facilitates specimen retrieval bag</td>
		</tr>
		<tr>
			<td>CO2 insufflator</td>
			<td>Stryker</td>
			<td>620-040-504</td>
			<td>Diagnostic laparoscopy</td>
		</tr>
		<tr>
			<td>CO2 insufflator tubing</td>
			<td>Stryker</td>
			<td>620-030-201</td>
			<td>Diagnostic laparoscopy</td>
		</tr>
		<tr>
			<td>Electrosurgical generator</td>
			<td>Covidien</td>
			<td>VLFT10GEN</td>
			<td>Diagnostic laparoscopy</td>
		</tr>
		<tr>
			<td>Foley kit and urometer bag</td>
			<td>Bard</td>
			<td>153214</td>
			<td>Diagnostic laparoscopy</td>
		</tr>
		<tr>
			<td>Laparoscopic scope, 5mm 0 degree</td>
			<td>Olympus</td>
			<td>WA4KL500</td>
			<td>Diagnostic laparoscopy</td>
		</tr>
		<tr>
			<td>Laparoscopic scope, 5mm 30 degree</td>
			<td>Olympus</td>
			<td>WA4KL530</td>
			<td>Diagnostic laparoscopy</td>
		</tr>
		<tr>
			<td>Laparoscopic suction irrigation pool tip</td>
			<td>Stryker</td>
			<td>250-070-406</td>
			<td>Suction irrigation, hemostasis, lysis of adhesions</td>
		</tr>
		<tr>
			<td>StrykeFlow II suction irrigator</td>
			<td>Stryker</td>
			<td>250-070-500</td>
			<td>Suction irrigation, hemostasis, lysis of adhesions</td>
		</tr>
		<tr>
			<td>Suction tubing</td>
			<td>Stryker</td>
			<td>250-070-403</td>
			<td>Suction irrigation, hemostasis, lysis of adhesions</td>
		</tr>
		<tr>
			<td>Suction/vacuum source</td>
			<td></td>
			<td></td>
			<td>Suction irrigation, hemostasis, lysis of adhesions</td>
		</tr>
		<tr>
			<td>Cystectomy and Salpingectomy</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>10mm tissue retrieval bag</td>
			<td>Covidien</td>
			<td>173050G</td>
			<td>Specimen retrieval bag to be used in 12mm laparoscopic trocar site</td>
		</tr>
		<tr>
			<td>Atraumatic laparoscopic bowel graspers</td>
			<td>Stryker</td>
			<td>250-080-319</td>
			<td>Lysis of adhesions, cystectomy, salpingectomy</td>
		</tr>
		<tr>
			<td>Bipolar Cord</td>
			<td>Stryker</td>
			<td>250-040-016</td>
			<td>Lysis of adhesions, cystectomy, salpingectomy</td>
		</tr>
		<tr>
			<td>Endopeanut laparoscopic retractor</td>
			<td>Covidien</td>
			<td>173019</td>
			<td>Lysis of adhesions, cystectomy, salpingectomy</td>
		</tr>
		<tr>
			<td>Harmonic ACE +7 ultrasonic shears</td>
			<td>Ethicon</td>
			<td>HARH23</td>
			<td>Lysis of adhesions, cystectomy, salpingectomy</td>
		</tr>
		<tr>
			<td>Laparoscopic bipolar grasping forceps</td>
			<td>Karl Storz</td>
			<td>38951 MD</td>
			<td>Lysis of adhesions, cystectomy, salpingectomy</td>
		</tr>
		<tr>
			<td>Laparoscopic curved Metzenbaum scissors</td>
			<td>Stryker</td>
			<td>250-080-267</td>
			<td>Lysis of adhesions, cystectomy, salpingectomy</td>
		</tr>
		<tr>
			<td>Ultrasonic generator unit</td>
			<td>Ethicon</td>
			<td>GEN11</td>
			<td>Lysis of adhesions, cystectomy, salpingectomy</td>
		</tr>
		<tr>
			<td>Vasopressin solution (20 units in 50 to 100cc of injectable saline)</td>
			<td></td>
			<td></td>
			<td>Cystectomy</td>
		</tr>
		<tr>
			<td>Chromopertubation</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>10mg methylene blue in 150mL 0.9% NaCl solution</td>
			<td></td>
			<td></td>
			<td>Pigmented solution for chromopertubation</td>
		</tr>
		<tr>
			<td>ZUMI uterine manipulator/injector</td>
			<td>Cooper Surgical</td>
			<td>ZSI1151</td>
			<td>Chromopertubation, diagnostic laparoscopy, lysis of adhesions</td>
		</tr>
		<tr>
			<td>Hemostatic agents</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Arista absorbable hemostatic particles 3g</td>
			<td>Bard Davol</td>
			<td>SM0002-USA</td>
			<td>Hemostatic agent</td>
		</tr>
		<tr>
			<td>Floseal gelatin thrombin matrix 5ml</td>
			<td>Baxter</td>
			<td>ADS201844</td>
			<td>Hemostatic agent</td>
		</tr>
		<tr>
			<td></td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>10mm tissue retrieval bag</td>
			<td>Covidien</td>
			<td>173050G</td>
			<td></td>
		</tr>
		<tr>
			<td>Arista absorbable hemostatic particles 3g</td>
			<td>Bard Davol</td>
			<td>SM0002-USA</td>
			<td>Hemostatic agent</td>
		</tr>
		<tr>
			<td>Atraumatic laparoscopic bowel graspers</td>
			<td>Stryker</td>
			<td>250-080-319</td>
			<td></td>
		</tr>
		<tr>
			<td>Endopeanut laparoscopic retractor</td>
			<td>Covidien</td>
			<td>173019</td>
			<td></td>
		</tr>
		<tr>
			<td>Floseal gelatin thrombin matrix 5ml</td>
			<td>Baxter</td>
			<td>ADS201844</td>
			<td>Hemostatic agent</td>
		</tr>
		<tr>
			<td>Harmonic ACE +7 ultrasonic shears</td>
			<td>Ethicon</td>
			<td>HARH23</td>
			<td></td>
		</tr>
		<tr>
			<td>Laparoscopic bipolar grasping forceps</td>
			<td>Karl Storz</td>
			<td>38951 MD</td>
			<td></td>
		</tr>
		<tr>
			<td>Laparoscopic curved Metzenbaum scissors</td>
			<td>Stryker</td>
			<td>250-080-267</td>
			<td></td>
		</tr>
		<tr>
			<td>Methylene blue 10mg in 150mL 0.9% NaCl solution</td>
			<td></td>
			<td></td>
			<td>For chromopertubation</td>
		</tr>
		<tr>
			<td>ZUMI uterine manipulator/injector</td>
			<td>Cooper Surgical</td>
			<td>ZSI1151</td>
			<td>For uterine manipulation and chromopertubation</td>
		</tr>
	</tbody>
</table>

surgical techniques to optimize ovarian reserve during laparoscopic cystectomy for ovarian endometrioma

Surgical management of ovarian endometrioma in patients desiring fertility is complicated by the need to balance maximal resection of disease with efforts to spare normal ovarian cortex. Optimization of tubal anatomy is another frequent consideration. Fertility-sparing laparoscopic techniques at the time of cystectomy for ovarian endometrioma seek to limit iatrogenic surgical damage to the ovarian cortex and strategically assess and respond to genital tract patency. Surgical candidates frequently desire relief from endometriosis-associated pain while also seeking to optimize spontaneous or assisted conception rates. Operative benefits include potential for surgical and histopathologic diagnosis of endometriosis, evaluation of genital tract patency, and treatment of visualized lesions. Resection of ovarian endometrioma nonetheless poses significant risks, including surgical injury, blood loss, post-surgical decline in ovarian reserve and post-operative inflammation with adhesion formation, both of which may impair folliculogenesis.
We present the case of a 32-year-old woman with known endometriosis and continued pain refractory to medical management who opted for surgical management of her disease tailored toward optimizing her chances at future conception. Using this case as an example, we describe techniques and considerations for diagnostic laparoscopy, adhesiolysis, ovarian cystectomy, chromopertubation, and salpingectomy with a focus on maintaining a fertility-preserving approach.

Table 1 shows results of our patient example. Total operation time was 251 min from anesthetic induction to extubation, with an estimated blood loss of 200 mL. The recovery period was uncomplicated. As she desired future pregnancy remote from the time of surgery, she began oral contraceptives. Histopathological examination revealed a right hydrosalpinx with paratubal cyst, bilateral endometriomas (4.5 cm and 3.7 cm), and ovarian tissue.
The surgery utilized a combination of fe...

Watch this Scientific Journal Video about Surgical Techniques to Optimize Ovarian Reserve during Laparoscopic Cystectomy for Ovarian Endometrioma at JoVE.com

Surgical Techniques to Optimize Ovarian Reserve during Laparoscopic Cystectomy for Ovarian Endometrioma

This protocol presents techniques to laparoscopically excise ovarian endometrioma, to perform adhesiolysis with sparing electrosurgical application, and to employ intraoperative chromopertubation to assess for genital tract patency. This systematic approach will facilitate optimal endometriosis management, guide concomitant adnexal surgeries, and enhance post-surgical fertility outcomes.

Surgical management of ovarian endometrioma in patients desiring fertility is complicated by the need to balance maximal resection of disease with efforts ...

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13.8K Views.  Montefiore Medical Center. This protocol presents techniques to laparoscopically excise ovarian endometrioma, to perform adhesiolysis with sparing electrosurgical application, and to employ intraoperative chromopertubation to assess for genital tract patency. This systematic approach will facilitate optimal endometriosis management, guide concomitant adnexal surgeries, and enhance post-surgical fertility outcomes.

Video: Surgical Techniques to Optimize Ovarian Reserve during Laparoscopic Cystectomy for Ovarian Endometrioma

Heterotypic Three-dimensional In Vitro Modeling of Stromal-Epithelial Interactions During Ovarian Cancer Initiation and Progression

Epithelial ovarian cancers (EOCs) are the leading cause of death from gynecological malignancy in Western societies. Despite advances in surgical treatments and improved platinum-based chemotherapies, there has been little improvement in EOC survival rates for more than four decades 1,2. Whilst stage I tumors have 5-year survival rates &gt;85%, survival rates for stage III/IV disease are &lt;40%. Thus, the high rates of mortality for EOC could be significantly decreased if tumors were detected at earlier, more treatable, stages 3-5. At present, the molecular genetic and biological basis of early stage disease development is poorly understood. More specifically, little is known about the role of the microenvironment during tumor initiation; but known risk factors for EOCs (e.g. age and parity) suggest that the microenvironment plays a key role in the early genesis of EOCs. We therefore developed three-dimensional heterotypic models of both the normal ovary and of early stage ovarian cancers. For the normal ovary, we co-cultured normal ovarian surface epithelial (IOSE) and normal stromal fibroblast (INOF)&nbsp;cells, immortalized by retrovrial transduction of the catalytic subunit of human telomerase holoenzyme (hTERT) to extend the lifespan of these cells in culture. To model the earliest stages of ovarian epithelial cell transformation, overexpression of the CMYC oncogene in IOSE cells, again co-cultured with INOF cells. These heterotypic models were used to investigate the effects of aging and senescence on the transformation and invasion of epithelial cells. Here we describe the methodological steps in development of these three-dimensional model; these methodologies aren't specific to the development of normal ovary and ovarian cancer tissues, and could be used to study other tissue types where stromal and epithelial cell interactions are a fundamental aspect of the tissue maintenance and disease development.

Heterotypic Three-dimensional In Vitro Modeling of Stromal-Epithelial Interactions During Ovarian Cancer Initiation and Progression

We describe methodologies for establishing in vitro heterotypic three-dimensional models comprising ovarian fibroblasts and normal ovarian surface or ovarian cancer epithelial cells. We discuss the use of these models to study stromal-epithelial interactions that occur during ovarian cancer development.

Epithelial ovarian cancers (EOCs) are the leading cause of death from gynecological malignancy in Western societies. Despite advances in surgical ...

Method for Obtaining Primary Ovarian Cancer Cells From Solid Specimens

Reliable tools for investigating ovarian cancer initiation and progression are urgently needed. While the use of ovarian cancer cell lines remains a valuable tool for understanding ovarian cancer, their use has many limitations. These include the lack of heterogeneity and the plethora of genetic alterations associated with extended in vitro passaging.&#160;Here we describe a method that allows for rapid establishment of primary ovarian cancer cells form solid clinical specimens collected at the time of surgery. The method consists of subjecting clinical specimens to enzymatic digestion for 30 min. The isolated cell suspension is allowed to grow and can be used for downstream application including drug screening. The advantage of primary ovarian cancer cell lines over established ovarian cancer cell lines is that they are representative of the original specific clinical specimens they are derived from and can be derived from different sites whether primary or metastatic ovarian cancer.

This study describes a detailed method for isolation and characterization of primary ovarian cancer cells from solid clinical specimens. Ovarian cancer clinical specimens are subjected to enzymatic digestion to obtain viable, fibroblast-free epithelial ovarian cancer (EOC) cells highly suitable for downstream applications.

Reliable tools for investigating ovarian cancer initiation and progression are urgently needed. While the use of ovarian cancer cell lines remains a ...

Murine Model for Non-invasive Imaging to Detect and Monitor Ovarian Cancer Recurrence

Epithelial ovarian cancer is the most lethal gynecologic malignancy in the United States. Although patients initially respond to the current standard of care consisting of surgical debulking and combination chemotherapy consisting of platinum and taxane compounds, almost 90% of patients recur within a few years. In these patients the development of chemoresistant disease limits the efficacy of currently available chemotherapy agents and therefore contributes to the high mortality. To discover novel therapy options that can target recurrent disease, appropriate animal models that closely mimic the clinical profile of patients with recurrent ovarian cancer are required. The challenge in monitoring intra-peritoneal (i.p.) disease limits the use of i.p. models and thus most xenografts are established subcutaneously. We have developed a sensitive optical imaging platform that allows the detection and anatomical location of i.p. tumor mass. The platform includes the use of optical reporters that extend from the visible light range to near infrared, which in combination with 2-dimensional X-ray co-registration can provide anatomical location of molecular signals. Detection is significantly improved by the use of a rotation system that drives the animal to multiple angular positions for 360 degree imaging, allowing the identification of tumors that are not visible in single orientation. This platform provides a unique model to non-invasively monitor tumor growth and evaluate the efficacy of new therapies for the prevention or treatment of recurrent ovarian cancer.

We describe a non-invasive animal imaging platform that allows the detection, quantification, and monitoring of ovarian cancer growth and recurrence. This intra-peritoneal xenograft model mimics the clinical profile of patients with ovarian cancer.

Epithelial ovarian cancer is the most lethal gynecologic malignancy in the United States. Although patients initially respond to the current standard of ...

Enrichment for Chemoresistant Ovarian Cancer Stem Cells from Human Cell Lines

Cancer stem cells (CSCs) are defined as a subset of slow cycling and undifferentiated cells that divide asymmetrically to generate highly proliferative, invasive, and chemoresistant tumor cells. Therefore, CSCs are an attractive population of cells to target therapeutically. CSCs are predicted to contribute to a number of types of malignancies including those in the blood, brain, lung, gastrointestinal tract, prostate, and ovary. Isolating and enriching a tumor cell population for CSCs will enable researchers to study the properties, genetics, and therapeutic response of CSCs. We generated a protocol that reproducibly enriches for ovarian cancer CSCs from ovarian cancer cell lines (SKOV3 and OVCA429). Cell lines are treated with 20 &#181;M cisplatin for 3 days. Surviving cells are isolated and cultured in a serum-free stem cell media containing cytokines and growth factors. We demonstrate an enrichment of these purified CSCs by analyzing the isolated cells for known stem cell markers Oct4, Nanog, and Prom1 (CD133) and cell surface expression of CD177 and CD133. The CSCs exhibit increased chemoresistance. This method for isolation of CSCs is a useful tool for studying the role of CSCs in chemoresistance and tumor relapse.

Cancer stem cells (CSCs) are&#160;implicated in tumor relapse due to chemoresistance. We have optimized a protocol for selection and expansion of CSCs from ovarian cancer cell lines. By treating cells with the chemotherapeutic cisplatin and culturing&#160;in a stem cell promoting media we enrich for non-adherent CSC cultures.

Cancer stem cells (CSCs) are defined as a subset of slow cycling and undifferentiated cells that divide asymmetrically to generate highly proliferative, ...

In vitro Enrichment of Ovarian Cancer Tumor-initiating Cells

Evidence suggests that small subpopulations of tumor cells maintain a unique self-renewing and differentiation capacity and may be responsible for tumor initiation and/or relapse. Clarifying the mechanisms by which these tumor-initiating cells (TICs) support tumor formation and progression could lead to the development of clinically favorable therapies. Ovarian cancer is a heterogeneous and highly recurrent disease. Recent studies suggest TICs may play an important role in disease biology. We have identified culture conditions that enrich for TICs from ovarian cancer cell lines. Growing either adherent cells or non-adherent &#8216;floater&#8217; cells in a low attachment plate with serum free media in the presence of growth factors supports the propagation of ovarian cancer TICs with stem cell markers (CD133 and ALDH activity) and increased tumorigenicity without the need to physically separate the TICs from other cell types within the culture. Although the presence of floater cells is not common for all cell lines, this population of cells with innate low adherence may have high tumorigenic potential.Compared to adherent cells grown in the presence of serum, TICs readily form spheres, are significantly more tumorigenic in mice, and express putative stem cell markers. The conditions are easy to establish in a timely manner and can be used to study signaling pathways important for maintaining stem characteristics, and to identify drugs or combinations of drugs targeting TICs. The culture conditions described herein are applicable for a variety of ovarian cancer cells of epithelial origin and will be critical in providing new information about the role of TICs in tumor initiation, progression, and relapse.

In vitro Enrichment of Ovarian Cancer Tumor-initiating Cells

Tumor-initiating cells (TICs) may represent a viable therapeutic target for the treatment of ovarian cancer, a highly recurrent and fatal disease. We present a protocol for culture conditions that enrich for this highly tumorigenic population of cells.

Evidence suggests that small subpopulations of tumor cells maintain a unique self-renewing and differentiation capacity and may be responsible for tumor ...

In Vivo and Ex Vivo Approaches to Study Ovarian Cancer Metastatic Colonization of Milky Spot Structures in Peritoneal Adipose

High-grade serous ovarian cancer (HGSC), the cause of widespread peritoneal metastases, continues to have an extremely poor prognosis; fewer than 30% of women are alive 5 years after diagnosis. The omentum is a preferred site of HGSC metastasis formation. Despite the clinical importance of this microenvironment, the contribution of omental adipose tissue to ovarian cancer progression remains understudied. Omental adipose is unusual in that it contains structures known as milky spots, which are comprised of B, T, and NK cells, macrophages, and progenitor cells surrounding dense nests of vasculature. Milky spots play a key role in the physiologic functions of the omentum, which are required for peritoneal homeostasis. We have shown that milky spots also promote ovarian cancer metastatic colonization of peritoneal adipose, a key step in the development of peritoneal metastases. Here we describe the approaches we developed to evaluate and quantify milky spots in peritoneal adipose and study their functional contribution to ovarian cancer cell metastatic colonization of omental tissues both in vivo and ex vivo. These approaches are generalizable to additional mouse models and cell lines, thus enabling the study of ovarian cancer metastasis formation from initial localization of cells to milky spot structures to the development of widespread peritoneal metastases.

In Vivo and Ex Vivo Approaches to Study Ovarian Cancer Metastatic Colonization of Milky Spot Structures in Peritoneal Adipose

We outline a protocol that implements both in vivo and ex vivo approaches to study ovarian cancer colonization of peritoneal adipose tissues, particularly the omentum. Furthermore, we present a protocol to quantitate and analyze immune cell-structures in the omentum known as milky spots, which promote metastases of peritoneal adipose.

High-grade serous ovarian cancer (HGSC), the cause of widespread peritoneal metastases, continues to have an extremely poor prognosis; fewer than 30% of ...

Quantitation of Intra-peritoneal Ovarian Cancer Metastasis

Epithelial ovarian cancer (EOC) is the leading cause of death from gynecologic malignancy in the United States. Mortality is due to diagnosis of 75% of women with late stage disease, when metastasis is already present. EOC is characterized by diffuse and widely disseminated intra-peritoneal metastasis. Cells shed from the primary tumor anchor in the mesothelium that lines the peritoneal cavity as well as in the omentum, resulting in multi-focal metastasis, often in the presence of peritoneal ascites. Efforts in our laboratory are directed at a more detailed understanding of factors that regulate EOC metastatic success. However, quantifying metastatic tumor burden represents a significant technical challenge due to the large number, small size and broad distribution of lesions throughout the peritoneum. Herein we describe a method for analysis of EOC metastasis using cells labeled with red fluorescent protein (RFP) coupled with in vivo multispectral imaging. Following intra-peritoneal injection of RFP-labelled tumor cells, mice are imaged weekly until time of sacrifice. At this time, the peritoneal cavity is surgically exposed and organs are imaged in situ. Dissected organs are then placed on a labeled transparent template and imaged ex vivo. Removal of tissue auto-fluorescence during image processing using multispectral unmixing enables accurate quantitation of relative tumor burden. This method has utility in a variety of applications including therapeutic studies to evaluate compounds that may inhibit metastasis and thereby improve overall survival.

Ovarian cancer metastasis is characterized by numerous diffuse intra-peritoneal lesions, such that accurate visual quantitation of tumor burden is challenging. Herein we describe a method for in situ and ex vivo quantitation of metastatic tumor burden using red fluorescent protein (RFP)-labeled tumor cells and optical imaging.

Epithelial ovarian cancer (EOC) is the leading cause of death from gynecologic malignancy in the United States.  Mortality is due to diagnosis of 75% of ...

Transplantation Into the Mouse Ovarian Fat Pad

Orthotopic transplantation assays in mice are invaluable for studies of cell regeneration and neoplastic transformation. Common approaches for orthotopic transplantation of ovarian surface and tubal epithelia include intraperitoneal and intrabursal administration of cells. The respective limitations of these methods include poorly defined location of injected cells and limited space volume. Furthermore, they are poorly suited for long-term structural preservation of transplanted organs. To address these challenges, we have developed an alternative approach, which is based on the introduction of cells and tissue fragments into the mouse fat pad. The mouse ovarian fat pad is located in the immediate vicinity of the ovary and uterine tube (aka oviduct, fallopian tube), and provides a familiar microenvironment for cells and tissues of these organs. In our approach fluorescence-labeled mouse and human cells, and fragments of the uterine tube are engrafted by using minimally traumatic dorsal incision surgery. Transplanted cells and their outgrowths are easily located in the ovarian fat pad for over 40 days. Long-term transplantation of the entire uterine tube allows correct preservation of all principle tissue components, and does not result in adverse side effects, such as fibrosis and inflammation. Our approach should be uniquely applicable for answering important biological questions such as differentiation, regenerative and neoplastic potential of specific cell populations. Furthermore, it should be suitable for studies of microenvironmental factors in normal development and cancer.

We describe an ovarian fad pad transplantation assay suitable for studies of normal and transformed epithelia of the female reproductive tract. The mouse fat pad allows transplantation of large tissue fragments, is easily accessible for surgery and imaging, and provides the most favorable native environment for tissues of M&#252;llerian origin.

Orthotopic transplantation assays in mice are invaluable for studies of cell regeneration and neoplastic transformation. Common approaches for orthotopic ...

Tubal Cytology of the Fallopian Tube as a Promising Tool for Ovarian Cancer Early Detection

Currently, it is widely accepted that the vast majority of ovarian high-grade serous carcinoma (HGSC) originate from the fallopian tube. However, due to the lack of markers or tools for the ovarian cancer identification, the early detection of HGSC remains challenging. Direct sampling of the fallopian tube can enhance sensitivity for detection of neoplastic cells when the tumor is not grossly visible. We developed a procedure to collect fallopian tube cells directly from freshly received surgical specimens, which has shown excellent correlation with histological findings. This approach lays a foundation for the future utility of minimally invasive laparoscopic screening in high-risk patient populations.

We explored a tubal cytologic method by sampling the fallopian tube directly post-surgical excision as a tool of ovarian cancer early detection. Here, we present a protocol to collect fallopian tube cells from freshly received surgical specimens.

Currently, it is widely accepted that the vast majority of ovarian high-grade serous carcinoma (HGSC) originate from the fallopian tube. However, due to ...

Laparoscopic Radical Left Pancreatectomy for Pancreatic Cancer: Surgical Strategy and Technique Video

Radical resection margins, resection of Gerota&#8217;s (perirenal) fascia, and adequate lymph node dissection are crucial for an adequate oncological resection of left-sided pancreatic cancer. Several surgical techniques have been described in recent years, but few were specifically designed for minimally invasive approaches. This study describes and demonstrates a standardized and reproducible technique for an adequate oncological resection of pancreatic cancer: laparoscopic radical left pancreatectomy (LRLP).
A 61-year-old woman presented with an incidental finding of a 3 cm mass in the left pancreas suspect for malignancy. Imaging did not reveal distant metastases, central vascular involvement, or morbid obesity, hence the patient was suitable for LRLP. This study describes the main steps of LRLP for pancreatic cancer. First, the lesser sac is opened by transecting the gastrocolic ligament. The splenic flexure of the colon is mobilized and the inferior border of the pancreas including Gerota&#39;s fascia is dissected down to the inferior border of the spleen. The pancreas is tunneled and hung, including Gerota&#8217;s fascia with a vessel loop. At the pancreatic neck, a tunnel is created between the pancreas and the portal vein, likewise a vessel loop is passed. The pancreas is then transected using the graded compression technique with an endostapler. Both the splenic vein and artery are transected before completing the resection. The entire specimen is extracted in a retrieval bag via a small Pfannenstiel incision.
Duration of the surgery was 210 min with 250 mL blood loss. Pathology revealed a R0-resection (&#62;1 mm) of a well-to-moderately differentiated adenocarcinoma originating from an intraductal papillary mucinous neoplasm. A total of 15 tumor-negative lymph nodes were resected. This is a detailed description of LRLP for left-sided pancreatic cancer as is currently being used within the international, multicenter randomized DIPLOMA (Distal Pancreatectomy Minimally Invasive or Open for PDAC) trial.

Oncologically safe left pancreatectomy requires radical resection (R0), Gerota&#8217;s (perirenal) fascia resection, and adequate lymph node dissection. This study describes the technical details of laparoscopic radical left pancreatectomy (LRLP), used in the first international multicenter randomized trial comparing minimally invasive with open left pancreatectomy for pancreatic cancer, the DIPLOMA trial.

Radical resection margins, resection of Gerota&#8217;s (perirenal) fascia, and adequate lymph node dissection are crucial for an adequate oncological ...