The Incidence of Port-Site Metastases in Gynecologic Cancers

To determine the incidence of port-site metastases in patients undergoing laparoscopic procedures for gynecologic cancers.  The charts of patients treated by laparoscopy for diagnosis, treatment, or staging of gynecologic cancers by the academic faculty attending physicians were studied from July 1, 1997 to June 30, 2001. No patient without a histological or cytological diagnosis of cancer from the index procedure were included. Fisher's exact test was used for statistical analysis.  Eighty-three patients were identified accounting for 87 procedures. Types of cancer treated included endometrial (39), ovarian (29), and cervical (14). Twenty procedures were performed for recurrence of ovarian or peritoneal cancer, and ascites was present in 10 cases. Port-site metastases occurred in 2 patients accounting for 8 sites. Five sites were diagnosed in a single patient 13 days after a second-look laparoscopy for stage IIIB ovarian cancer, and 3 sites were diagnosed in a patient 46 days after an interval laparoscopy for stage IIIC primary peritoneal cancer. Ascites was present in both patients. The overall incidences of port-site metastases per procedure and per port placed were 2.3% (2/87) and 2.4% (8/330), respectively. In patients with a recurrence of ovarian or peritoneal cancer, no port-site metastases (0/16) occurred in the absence of ascites, whereas 50% (2/4) of patients with ascites developed port-site metastases (P<.035).  The overall incidence of port-site metastases in gynecologic cancers in our study was 2.3%. The risk of port-site metastases is highest (50%) in patients with recurrence of ovarian or primary peritoneal malignancies undergoing procedures in the presence of ascites.

Related papers:

title: Ovarian carcinoma metastatic to the diaphragm--frequently undiagnosed at laparotomy. A preliminary report.
abstract: Peritoneoscopy was performed four weeks after diagnostic laparotorny in 14 patients with ovarian carcinoma. In 11 of these patients, diaphragmatic metastases were found, and in seven it was the only site of upper abdominal metastasis. One of the patients with diaphragmatic metastases had been thought to have had completely resected Stage IA disease, prior to peritoneoscopy. In patients with ovarian carcinoma, physicians should search carefully for diaphragmatic metastases, by direct visualization of the diaphragm. A high incidence of diaphragmatic metastasis is a possible explanation for the frequent failure of radiotherapy to cure ovarian carcinoma, and shielding of the liver during radiotherapy may be detrimental.

title: Peritoneoscopy: a valuable staging tool in ovarian carcinoma.
abstract: Peritoneoscopy was done within 1 month of exploratory laparotomy in 30 consecutive patients, with ovarian carcinoma as part of their pretreatment evaluation. Six of the 7 patients who were thought to have ovarian carcinoma localized to the pelvis (stages I and II) were found to have advanced disease (stage III) at peritoneoscopy and thus required a change in therapy. Metastatic diaphragmatic involvement in ovarian carcinoma is common and was found in 77 percent of all patients studied. The routine shielding if the liver area ordinarily used with total abdominal radiotherapy would select these patients for therapeutic failure. Peritoneoscopy supplied reevaluable finding in 2 of 7 patients having normal physical, roentgenologic, and laboratory examinations, as well as in 93 percent of all patients stuided. "Second look" peritoneoscopy precluded the need the laparotomy in 5 to 13 patients achieving as apparent clinical remission.

title: Operative Gynecologic Laparoscopy: Principles and Techniques
abstract: This book will be of interest to a broad segment of gynecologic surgeons. The beginning laparoscopist will find the chapter on basic techniques useful, and the experienced laparoscopist will be interested in the chapters on new techniques pioneered by Dr. Nezhat and his coauthors. The first part of the book discusses patient education and informed consent, topics usually found in the back of surgical texts. This position rightfully underscores the importance of communication between surgeon and patient. It also speaks of the litigious environment in which we surgeons find ourselves today. A commendable feature of the publication is the line drawings that illustrate the text. The artist's work is effectively and abundantly used and contributes significantly to the reader's understanding. The text is concise and thorough, with good references for additional reading. The cover is eye-catching red with gold letters on a black background. The layout is also attractive throughout with a good use of white space. A departure from the typography tradition of textbooks is this book's use of type fonts. The front matter appears in one font, and the chapter text is in another. The book is comprehensive, with 21 chapters. The authorship of each chapter is not given, but some contributors' work can be recognized if one knows their prior publications. The topics include all of the current major applications of laparoscopy and several in the development stage. The chapter on equipment includes a broad array of insmmaentation. As I would expect from these authors, it also contains an excellent discussion of video in laparoscopy. The use of electronic images in laparoscopy, which the authors have championed, has rapidly moved from academic to essential in today's visual era. Laser, another modem tool, is discussed together with electrosurgery energy. The main section of the book is devoted to specific laparoscopic procedures. Adhesiolysis, ectopic pregnancy, endometriosis, ovarian cysts, tubal and uterine surgery, appendectomy, presacral neurectomy, uterosacral nerve transection, pelvic reconstruction, and oncology are effectively discussed. These chapters describe the authors' operative techniques and outcomes, and review other clinical series. Preoperative and postoperative evaluations and laboratory tests are included. The closing chapters review complications, their prevention, and management. The book also has a question-and-answer section, the format of which is usually seen in periodicals. Its paragraph indention style I found distracting. However, it provides helpful information. An unnumbered six-page color atlas appears at the end of the book. My overall opinion of this addition to printed laparoscopy resources is that it is very valuable. It belongs in our libraries. The Doctors Nezhat and coauthors are to be commended.

title: Laparoscopic lymphadenectomy for gynecologic malignancies.
abstract: The purpose of our study was to detail our 5-year experience with laparoscopic lymphadenectomy for gynecologic malignancies.



From 11/5/92 to 3/9/98, we performed laparoscopic lymphadenectomies on 94 patients with various gynecologic malignancies. Pelvic, paraaortic, and combinations of both pelvic and paraaortic lymphadenectomies were performed depending on the primary site of disease and indication for lymph node dissection. Data were prospectively collected on all patients.



From 11/5/92 to 3/9/98 we performed 94 laparoscopic lymphadenectomies for gynecologic malignancies. The distribution included 64 patients with cervical cancer, 14 with ovarian cancer, 12 with endometrial cancer, 2 with fallopian tube cancer, 1 with a uterine malignant mixed mesodermal tumor, and 1 with a metastatic neuroendocrine tumor. Fifty-five patients had only pelvic lymph node dissections, 9 patients had paraaortic dissections only, and 30 had both pelvic and paraaortic dissections performed. Among 30 patients having laparoscopic lymphadenectomy only, the mean hospital stay was 3.6 days. Included in this group were 19 patients who received postoperative neoadjuvant chemotherapy for cervical cancer as inpatients prior to ambulatory radiation therapy. The mean length of stay for this group was 4.6 days versus 1.7 days for the 11 patients who did not receive postoperative chemotherapy (P = 0.0025). The mean number of pelvic nodes was 11.9 (range 0-57), with a mean of 4. 5 between 11/5/92 and 12/31/95 and a mean of 19.1 from 1/1/96 to 3/9/98. The mean number of paraaortic nodes obtained was 3.7 (range 0-14), with a mean of 3.4 from 11/5/92 to 12/31/95 and a mean of 4.1 from 1/1/96 to 3/9/98. A total of 3 patients required conversions to laparotomy. One was for a vascular injury to the vena cava, 1 for a large tumor extending to both sidewalls, and the third for removal of densely matted lymph nodes.



Laparoscopic lymphadenectomy is a technically feasible procedure for patients with gynecologic malignancies requiring lymph node dissections, with an acceptable safety profile and nodal yield. The number of nodes obtained increased in direct proportion to operator experience. In addition, patients may benefit from a decrease in hospital stay compared to conventional lymphadenectomy via laparotomy.

title: Risk factors contributing to early occurrence of port site metastases of laparoscopic surgery for malignancy.
abstract: In this article, the authors present an up-to-date review of our experience and that of the medical literature encompassing all important aspects of port site metastases after laparoscopic surgery for malignancy and to search for potential risks with contribution to early occurrence of port site metastases after laparoscopic surgery. We used a Medline computer database search to conduct for pertinent articles through September 1996. Cross-referencing identified additional publications. We found that the majority of recurrences were in patients with adenocarcinoma cell type, advanced stage (far-advanced disease), and often with diffuse peritoneal carcinomatosis, suggesting that port site metastases may contribute to the highly aggressive nature of the disease. Risk factors that contributed to early occurrence of port site metastases were ovarian cancers, presence of ascites, and diagnostic or palliative procedures for malignancy (P < 0.0001, P = 0.008, and P < 0.001, respectively). Practitioners should exercise extreme caution when using laparoscopic techniques to manage the care of these patients.

title: Rapid development of malignant metastases in the abdominal wall after laparoscopy.
abstract: The authors describe a case of developing local tumor metastases after laparoscopy. In the second week after laparoscopy metastases developed at the place of the penetration of the pneu-needle and the trocar by the mediation of ascites containing malignant cell groups. This form of metastatisation seems to be extremely rare.

title: Abdominal wall metastasis following laparoscopy: a case report.
abstract: Laparoscopy is commonly used for diagnosis and follow up of malignant disease. Metastatic infiltration of the scar is very rare. We report a case which presented as acute inflammation within 8 days of the procedure.

title: Abdominal wall metastases from ovarian cancer after laparoscopy.
abstract: We report three cases of abdominal wall metastases from ovarian cancer after laparoscopy. The implants occurred at the site of insertion of laparoscopy trocars. One patient had an implant of serous papillary carcinoma of low malignant potential at the trocar sites after laparoscopic oophorectomy. Laparoscopic surgery is inappropriate in patients with malignant ascites or when preoperative or intraoperative findings are suggestive of ovarian cancer.

title: Abdominal‐wall tumor implantation after laparoscopy for malignant conditions
abstract: To determine the incidence of abdominal-wall tumor implantation after laparoscopic procedures in patients with known malignancies.  We reviewed 557 laparoscopic procedures performed by the Gynecologic Oncology Service between November 1990 and February 1994. In 105 procedures, malignancy was documented cytologically or histologically, 88 with intraperitoneal disease and 17 with retroperitoneal disease. Ovarian cancer represented 80% (70 of 88) of the procedures with intraperitoneal malignancy, and the remaining cases consisted of carcinoma of the fallopian tube (two), endometrium (11), cervix (one), breast (three), and stomach (one). Histologically, ovarian carcinomas ranged from low malignant potential to poorly differentiated. Among 88 patients with intraperitoneal disease, 77 had gross disease and 11 had microscopic disease. Four hundred thirty-seven different abdominal-wall puncture sites were used (38 Veress needle sites and 399 laparoscopic ports).  One of the 437 (0.2%) abdominal-wall puncture sites developed implantation, a frequency of 1.0% (one in 105) per procedure; this developed after a second-look laparoscopic procedure for ovarian carcinoma in which only microscopic disease was present. If only intraperitoneal disease is considered, the incidence of implantation was 0.3% (one in 363) per abdominal puncture and 1.1% (one in 88) per procedure.  Tumor implantation at the abdominal-wall puncture site is an infrequent occurrence after laparoscopy in patients with intraperitoneal and retroperitoneal carcinoma.

title: Incidence and effect on survival of abdominal wall metastases at trocar or puncture sites following laparoscopy or paracentesis in women with ovarian cancer.
abstract: The aim of this retrospective study was to examine the incidence and prognostic significance of abdominal wall metastases in patients with ovarian cancer present at the primary debulking at the entry sites of previous laparoscopy or paracentesis. The clinical records of 219 patients were studied. In 7 of 43 patients (16%) who had undergone laparoscopy and 3 of 30 patients (10%) who had undergone paracentesis previous to the primary debulking, an abdominal wall metastasis had developed at the entry sites. All metastases occurred in patients with FIGO stage IIIC-IV including ascites. Survival analysis using the Cox proportional hazards model showed that after adjustment for age, FIGO stage, histology, grade, ascites, and residual disease after primary debulking, the presence of abdominal wall metastases in the entry sites of previous laparoscopy or paracentesis was negatively, although not statistical significantly, correlated with survival (P = 0.14).

title: Spread of ovarian cancer after laparoscopic surgery: report of eight cases.
abstract: The aim of this study was to describe early occurrences of metastases after laparoscopy of ovarian masses later found to be malignant.



The hospital charts of eight women having undergone laparoscopic surgery for ovarian mass were reviewed and analyzed.



The mean age of the patients was 40 years (range 25 to 66). Size of the tumor ranged from 2 to 15 cm. In four patients the ovarian mass was suspected to be malignant in the laparoscopy. Diagnostic procedure (biopsy of the tumor) was performed in two and salpingo-oophorectomy in six patients. Staging laparotomy was performed within the mean of 17 days (range 7-29). In four patients (50%) the cancer had spread from a localized to an advanced stage during the delay. Ascites was present in the laparoscopy in two of the four patients with port site or abdominal wall metastases.



Laparoscopic surgery of ovarian mass later found to be malignant can cause considerable and early spread of the cancer.

title: Port site metastasis after laparoscopy for gynecological cancer: report of two cases.
abstract: Port-site metastasis (PSM) is the most common complication consecutive to laparoscopic management of cancers. It has largely been reported as a complication of surgery for colon cancers or unsuspected gallbladder cancers (1). In gynecologic oncology, most cases occurred after laparoscopy for ovarian cancers (especially at advanced stage) or endometrial cancers. We report here two particular cases of PSM which raise questions on PSM mechanism.

title: Trocar implantation metastasis after laparoscopy in patients with advanced ovarian cancer: can the risk be reduced?
abstract: The purpose of this study was to determine risk factors for trocar implantation metastasis after diagnostic laparoscopy in patients with primary or recurrent advanced ovarian cancer.



Eighty-three women with primary advanced ovarian cancer and 21 women with recurrent ovarian cancer undergoing a laparoscopy for a tissue diagnosis and for assessment of operability were included in the study. The occurrence of implantation metastasis at the trocar incision scars was analyzed according to clinicopathologic characteristics.



A recurrence developed at the trocar site in 7 (58%) of 12 patients undergoing a laparoscopy in which only the skin was closed at the end of the procedure and in 2 (2%) of 92 patients undergoing a laparoscopy with closure of all layers (odds ratio, 63; 95% confidence interval, 10.3-385; P <.001). The International Federation of Gynecology and Obstetrics stage at initial presentation, tumor histologic type, tumor differentiation, maximal tumor diameter at the time of diagnosis, estimated weight of the metastatic tumor, residual tumor after cytoreductive surgery, surgical characteristics, and type of chemotherapy were well balanced among both groups. Patients with implantation metastasis had significantly more ascites (median, 700 mL vs 300 mL; P =.032) and a longer interval between the start of platinum-based chemotherapy or cytoreductive surgery (median, 6 days vs 17 days; P <.01) compared with patients without abdominal wall recurrence. A palpable abdominal wall metastasis developed in none of the patients undergoing a laparoscopy with closure of all layers of the abdomen followed by cytoreductive surgery or chemotherapy within 1 week after the laparoscopy. Kaplan-Meier survival analysis showed that patients with abdominal wall implantation metastasis had a survival rate similar to that of the other patients.



Laparoscopy with careful closure of the peritoneum, rectus sheath, and skin followed by chemotherapy or cytoreductive surgery with excision of the trocar trajectories within 1 week is safe in patients with disseminated ovarian cancer.

title: An umbilical metastasis after laparoscopy for squamous cell carcinoma of the cervix.
abstract: Laparoscopic surgical techniques are being used with increasing frequency in patients with gynecologic malignancies. Abdominal wall metastases to trochar sites have been described after treatment for ovarian cancer and other adenocarcinomas but are very rare in patients with squamous cell carcinomas. We present a case of metastasis to a laparoscopic trochar site in a patient with squamous cell carcinoma of the uterine cervix. While this may be an unusual event, there is some concern that laparoscopy could disseminate otherwise isolated pelvic disease.

title: Port-site metastasis following laparoscopic lymphadenectomy for adenosquamous carcinoma of the cervix.
abstract: Although incisional metastases following surgery for cervical cancer are extremely rare, port-site disease following minimal-access surgery is becoming increasingly reported. We report a case of a metastasis which occurred at a port site following laparoscopic removal of lymph nodes affected by cervical adenosquamous carcinoma. This report adds to the literature suggesting that cutaneous tumor deposition may be enhanced by this method of surgery.

title: Laparoscopic port-site metastasis of an early stage adenocarcinoma of the cervix with negative lymph nodes.
abstract: Port-site metastasis (PSM) following laparoscopic surgery for cancer is being increasingly recognized as a potential problem; the majority of cases appear following laparoscopy for a pelvic mass that subsequently proved to be malignant or in the case of a disseminated intraperitoneal disease. The rare cases of PSM following laparoscopy for endometrial and cervical cancer have all been associated with the presence of regional lymph node metastasis or disseminated disease in the peritoneal cavity. We present here a case report of PSM in the absence of spread beyond the primary tumor.



A 48-year-old woman with stage IA1 adenocarcinoma of the cervix was treated with laparoscopically assisted vaginal hysterectomy, bilateral salpingo-oophorectomy, and bilateral pelvic node dissection. The pathologic study revealed an endocervical adenocarcinoma confined to the cervix with negative lymph nodes. Nine months postoperatively, a cutaneous metastasis at the port-site was diagnosed. This was treated with wide local excision of the recurrence and the port-site track. Explorative laparotomy and para-aortic node sampling showed no evidence of recurrence elsewhere.



This case emphasizes the risk for PSM in laparoscopic surgery performed for early stage disease.

title: Port site metastasis after laparoscopic-assisted vaginal hysterectomy for endometrial cancer: possible mechanisms and prevention.
abstract: Only 19 cases of metastases at the cannula insertion site after laparoscopy for gynecological malignancy have been reported in the literature. One case has been diagnosed with cervical squamous cell carcinoma, whereas the others have been diagnosed with ovarian cancer and borderline ovarian tumor. We present a novel case of laparoscopy-site abdominal wall metastasis from endometrial cancer after laparoscopic-assisted vaginal hysterectomy (LAVH). The 56-year-old female patient exhibited metastases of an abdominal wall trocar site and a perineal site after undergoing LAVH and laparoscopic-assisted (LA) bilateral pelvic lymph node sampling as well as LA para-aortic lymph node sampling for treating endometrial carcinoma, surgical staging IIIC, G3. The interval between the surgical extirpation of endometrial carcinoma and diagnosis of the tumor recurrence was 6 months, suggesting that overmanipulation of the diseased organ during laparoscopic surgery may have resulted in tumor spillage, intraperitoneal dissemination, and wound contamination. Although this procedure has been proven beneficial to patients with benign disease or early-stage gynecologic malignancies, laparoscopic-assisted vaginal hysterectomy may not be efficacious to eradicate advanced gynecological malignancy.

title: Port-site metastases of adenocarcinoma of the fallopian tube after laparoscopically assisted vaginal hysterectomy and salpingo-oophorectomy
abstract: Port-site metastases following laparoscopic surgery for cancer constitute an emerging problem. We report a case of cutaneous metastasis at a port site following laparoscopically assisted vaginal hysterectomy and salpingo-oophorectomy for unsuspected adenocarcinoma of the fallopian tube. This complication occurred 7 months postoperatively and was treated with resection. A single site was involved. Possible etiologies are implantation from ``contaminated'' instruments or dissemination of tumor cells by the positive-pressure pneumoperitoneum. Preventive measures include precise and clean surgical technique, the use of a nonporous bag, postoperative trocar-site excision or irradiation, and conversion to laparotomy either intra- or postoperatively.

title: Implantation metastasis of ovarian cancer after third-look laparoscopy.
abstract: Laparoscopy is used as a diagnostic and therapeutic tool in gynecologic oncology, including the follow up of patients with known ovarian carcinoma. It offers an excellent magnified view of pelvis and anterior abdominal contents. In addition, the operator can easily obtain specimens from suspected sites of involvement and can make laparoscopy guided washings. We present a case of tumor implant occurring in the abdominal trocar site of ovarian papillary cystadenocarcinOma of a patient with known ovarian carcinoma. The purpose of this report is to call attention to the fact that this diagnostic procedure may result in tumor implantation in the abdominal wall even in the absence of visible intraperitonealtumoral involvement in ovarian carcinoma. To our knowledge, there has not been any reported case of abdominal trocar site implant following third-look laparoscopy.

title: Rationale for integrating early postoperative intraperitoneal chemotherapy into the surgical treatment of gastrointestinal cancer.
abstract: A new concept in the natural history of gastrointestinal (GI) cancer suggests that recurrence of this malignancy can be separated into two types. Hematogenous and lymphatic metastases occur before surgical removal of the primary cancer. The spread of cancer to the resection site and to peritoneal surfaces occurs at the time of surgical removal of the primary tumor. Surgical trauma leads to a dispersal of malignant tumor emboli, which then implant within the raw tissue surfaces of the resection site and abraded peritoneal surfaces. Instillation of chemotherapy directly into the peritoneal cavity, as part of GI surgery, provides cytotoxic levels of drug that may change the natural history of GI cancer. The most common sites of disease recurrence have been, in the past, at the resection site and on peritoneal surfaces. With the optimal use of intraperitoneal chemotherapy, these sites of surgical treatment failure should no longer occur. Early phase I and II and pharmacologic studies suggest that an effective dose and schedule have been achieved, that toxicity is at reasonable levels, and that responses with small volumes of intra-abdominal cancer are exceptionally high. Chemotherapy that has an impact on the surgical event by decreasing cancer spread to the resection site and to peritoneal surfaces may significantly improve survival and quality of life in patients with GI cancer.

title: Port site metastasis of ovarian carcinoma remote from laparoscopic surgery for benign disease.
abstract: The use of laparoscopic surgical procedures has continued to expand due to the many advantages that this surgical approach offers. However, as we continue to realize the benefits and expand the scope of laparoscopic procedures, new complications may occur.



This is the case of a 77-year-old gravida 2 para 2 who underwent exploratory laparotomy and surgical staging with optimal cytoreduction for Stage IIIC papillary serous ovarian carcinoma in February 1998. Her past surgical history was significant for total abdominal hysterectomy and left salpingo-oophorectomy in 1955 for symptomatic leiomyomata and for a laparoscopic cholecystectomy in July 1997. After initial platinum-based chemotherapy, she presented with an enlarging nodule at the right upper quadrant laparoscopic port site. Fine needle aspiration confirmed recurrent papillary serous ovarian carcinoma. After a discussion of her options, she elected to undergo surgical resection with postoperative salvage chemotherapy.



Port site recurrences have been previously reported in patients who underwent initial surgical evaluation for ovarian carcinoma utilizing the laparoscopic approach. However, it is unusual for recurrent cancer to appear in port sites or operative incisions not related to the initial cancer surgery. This report serves to caution the gynecologic oncologist that the first evidence of recurrence may be at a laparoscopic port site from prior benign gynecologic or nongynecologic surgery.

title: Port site recurrences after laparoscopic surgery. A review.
abstract: Port site metastasis has been a surprising event after laparoscopic procedures in cancer patients. No clear data exist about this phenomenon. The aim of this study is to summarize current epidemiologic knowledge about the risk of this complication. A review of all case reports about port site recurrences was undertaken. To date, 164 cases of port site metastases after videoscopic procedures have been reported in 90 papers. We found 108 cases of implantation after laparoscopy for digestive tumors, 23 after thoracoscopy, 29 after gynecological and 4 after urological laparoscopy. Analysis of the current literature confirms that laparoscopy is associated with abdominal cell mobilization to the trocars and instruments. Also low-staged and highly differentiated tumors have been reported to cause post-laparoscopy tumor seeding. The temporary data of the CAE registry 'port site metastases' (Workgroup for Surgical Endoscopy of the German Society of Surgery) are also reported. The analysis of 80 histologically confirmed cases of port site recurrence shows a particular frequency after laparoscopic cholecystectomy for unsuspected gallbladder cancer (n = 59). Postoperative specimen examination revealed a T1 carcinoma in 9 cases (15%), T2 carcinoma in 33 (21%), T3 in 3 (5%) and T4 in 1 case (1.7%). The mean time to clinical tumor relapse was 6 months. Similar patterns were found in a lower number of port site metastases after laparoscopy for colon cancer (n = 2) and for other cancers (n = 9). Clinical evidence that laparoscopy with CO2 pneumoperitoneum can enhance tumor dissemination is given. Port site metastases seem to be secondary to multiple factors including the gas used, local trauma, tumor manipulation, biologic properties of the tumor, and individual surgical skills.

title: A proposed model for the movement of cells within the abdominal cavity during CO2 insufflation and laparoscopy.
abstract: The application of laparoscopic-assisted surgery to gastrointestinal malignancy has lead to the recurrence of malignancy in wounds created during these procedures by laparoscopic ports.



Possible mechanisms of this complication have been studied in an in vitro model. Using filter systems, we have examined the expelled carbon dioxide used during laparoscopy and the laparoscopic ports and instruments for the presence of malignant cells.



No malignant cells were identified in the exhaust CO2 examined, whereas all instruments and laparoscopic ports were contaminated by malignant cells.



These findings suggest that direct contamination by the instruments and ports and not dispersion of malignant cells by CO2 is the route by which port seeding of tumour cells occurs.

title: The incidence of port-site metastases might be reduced

abstract: AbstractBackground: Laparoscopic resection for cancer is controversial and port-site metastases are not infrequent. The mechanisms of occurrence of port-site metastases remain unclear. Animal experiments have suggested a role for carbon dioxide (CO2), but port-site metastases also occur after thoracoscopy, where no CO2 is used. The aim of this study was to define the role of CO2 in the seeding of tumor cells in the human patient.

 Methods: CO2, instruments, trocars, suction device, and peritoneal washing were examined during 12 staging laparoscopies for pancreatic cancer. The presence, viability, and biological significance of cells were investigated using conventional cytology, polymerase chain reaction (PCR), and restriction fragment length polymorphisms (RFLPs) to detect the presence of a mutant k-ras gene as a genetic marker of cancer cells.

  Cytology exam of peritoneal washing, instruments, the suction device, and trocars revealed many cells. Tumor cells were detected in 6/12 peritoneal, in 4/12 trocars and 4/11 instruments washings, but not in 12 CO2 samples. The DNA content of CO2 was very low—as assessed by PCR. Mutant DNA was detected by RFLP in four out of 12 aerosols. Six aerosols did not contain any DNA. Two aerosols were borderline.

  During staging laparoscopy for pancreatic cancer in humans, CO2 contains only very low levels of free-floating tumor cells, even in the presence of massive peritoneal contamination. These results suggest that the incidence of port-site metastases might be reduced if mechanical contamination of the port sites with instruments or with the specimen can be avoided.

title: Influence of peritoneal factors on port‐site metastases in a xenograft ovarian cancer model
abstract: We determine the main physical effects of pneumoperitoneum on tumour dissemination and port‐site metastases occurrence.