- Email: [email protected]
Go Retro: When the Going Gets Tough Go Retroperitoneal
Abstracts / Journal of Minimally Invasive Gynecology 21 (2014) S191–S227 A 26-year-old woman in her first pregnancy at 18 weeks of gestation went to the emergency room with abdominal pain at left lower quadrant and inguen complicated with omitting, low fever and uterine contraction. Ultrasound showed intrauterine twin pregnancy and found a hypoecho solid mass at left adnexal area with a size of 81 mm x 59 mm x 57 mm and CDFI did not show any flow signals in or around the mass. A diagnosis of adnexal torsion was considered and an emergency laparoscopic exploration was performed. Laparoscopic view showed purple left ovary and fallopian tube with torsion and infarction. Adnexectomy of the left side was performed. The pathology diagnosis revealed extensive hemorrhage and necrosis of ovary and fallopian tubal and ovarian tissue. At 38 weeks of gestation, she delivered spontaneously two healthy infants. The aim of this video is to present a safe laparoscopic technique during mid-term pregnancy. 694 Safe and Fast Retrieval of Huge Myoma and Ovarian Tumor in Laparoscopic Surgery Fukuda M, Andou M, Nakajima S, Yanai S. Gynecology, Kurashiki medical center, Kurashiki, Okayama, Japan Background: Laparoscopic surgery is a frequently performed surgical technique in the gynecologic field. Laparoscopic surgery is superior in recovery time, pain relief, and cosmetic results. In this study, we discuss the safe and fast retrieval route of large pathology in laparoscopic surgery. Methods: Case 1 is a patient who underwent TLH and BSO for a large ovarian tumor (mature teratoma) measuring 12cm in diameter. Case 2 is a myomectomy patient with multiple myomas. Case 3 is a myomectomy patient with a huge myoma measuring 20cm in diameter. Results: The safe and fast retrieval of large myomas and ovarian tumors requires cooperation between the operator and the assistant. Morcellation by cold knife or scissors is faster and more economical compared with other instrument methods. Transvaginal retrieval is useful, but it requires higher skill. Thus, before performing surgery, training and experience is essential.
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This video demonstrates how total laparoscopic hysterectomy of a large voluminous fibroid uterus can be achieved by using instruments and techniques that help improve visualization and accomplish safe dissection. 697 Single Port Para Aortic Lymphadenectomy: Tips and Tricks Jennings AJ, Al-Niaimi A. Department of Ob/Gyn, University of Wisconsin, Madison, Wisconsin This video displays three recommended surgical tips to help optimize para aortic lymphadenectomy using Single Port Laparoscopy. The video begins with the standard entry into the abdomen. Visualization of the techniques, as well as reminders of pelvic anatomy are provided. In addition, the video focuses on the unique challenges caused by a patient’s obesity and ways to improve visualization in those circumstances. 698 Laparoscopic Myomectomy with New Vaginal Morcellation Kim D, Byon M, Kim H. Chung-ang University Hospital, Seoul, Korea The introduction of electomechanical morcellation reduced the procedure time, but still morcellation is the most time-consuming part of the entire procedure in the cases of huge mass. Especially when removing a huge uterine mass, we believe a morcellator with a diameter of 20 mm is the most suitable but it will create a large scar, roughly the size of morcellator being applied. Bigger sized morcellator is preferred to avoid prolongation of operation time, but accompanied additional skin incision which causes more post-operative pain and less cosmetic effect, does not correspond to the requirements of minimally invasive surgery. we carried out morcellation by the vaginal route using Semm’s morcellation sets. Thus, vaginal morcellation could be an easy way to overcome the limit and strengthen the laparoscopic operation. With this technique, there is no need to enlarge any of the abdominal port sites to accommodate the morcellator.
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Robotic Single-Port Hysterectomy Gungor M, Ozbasli E, Kahraman K, Genim C. Obstetrics and Gynecology Department, Acibadem University, Faculty of Medicine, Istanbul, Turkey
Laparoscopic Preconceptional Transabdominal Cervico-Isthmic Cerclage (TCIC) Koh AR,1 Choi JS,1 Bae J,1 Lee WM,1 Ko JH,2 Ju W.3 1Hanyang University College of Medicine, Seoul, Republic of Korea; 2Kangwon National University Hospital, Chuncheon, Gangwon-do, Republic of Korea; 3Ewha Womans University School of Medicine, Seoul, Republic of Korea
Background/Hypothesis: Single- port robotic surgery is a promising surgical frontier Methods and Materials: The video shows a case of single-port robot assisted hysterectomy that was performed to a 53- year old patient who has a body mass index of 39. The indication was postmenopausal bleeding and leiomyoma. Results: The operation time was 60 minutes. The bleeding was 100 cc. No intraoperative and postoperative complication was observed. The patient was discharged on postoperative day 1 with no problem. Conclusion: Single- port robotic surgery has better cosmesis, minimizes the potential morbidity, decreases postoperative analgesia and has a shorter convalescence period. More prospective studies are needed. 696 Tips and Surgical Technique for Minimally Invasive Hysterectomy in a Patient with Massive Fibroid Uterus Jan A,1 Campian C,2 Tatalovich J.3 1Ob/Gyn, Medstar Franklin Square Hospital Center, Baltimore, Maryland; 2Urogynecology, St. Louis University, St. Louis, Missouri; 3Urogynecology, Heritage Medical Associates, Nashville, Tennessee T.K. is a 52 year old female with a BMI of 42 who presented to the hospital with pelvic pain and was found to have a massive fibroid uterus measuring approximately 32-35 cm. The patient strongly desired minimally invasive surgery and delayed surgery for many years from fear of laparotomy.
A 33-year-old Korean woman underwent laparoscopic radical trachelectomy, bilateral laparoscopic pelvic lymphadenectomy, and transvaginal cerclage using a Ethibond in 2008. The final histopathological report showed squamous cell carcinoma confined to the uterine cervix, with the maximum size of 9mm and no lymph node metastasis. She was referred to our clinic due to recurrent midtrimester miscarriages and anatomical cause of incompetent cervix. We performed laparoscopic preconceptional transabdominal cerclage using a 5mm Mersilene band on the avascular space, between the uterine arteries and bifurcation of the ascending branch, at the level of uterine cervicoisthmic junction. 700 Go Retro: When the Going Gets Tough Go Retroperitoneal Kondrup JD, Sylvester BA, Branning ML. Lourdes Hospital, 169 Riverside Drive, Binghamton, New York As I teach MIGS courses around the world I find that many laparoscopic surgeons are intimidated by entering the retroperitioneal space to either dissect out the ureter or ligate the uterine artery at its origin. The gynecologic oncologist feels very comfortable here and enters this space
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Abstracts / Journal of Minimally Invasive Gynecology 21 (2014) S191–S227
immediately during oncology surgery. This video demonstrates how to enter the retroperioneal space for gynecologists and to locate the ureter and the uterine artery. It illustrates easy steps and ends with a difficult case showing the technique of dissection. The laparoscopic GYN surgeon will find this video helpful in getting started in entering this space. We say, ‘‘When the going gets tough; GO RETRO.’’ 701 A Systematic Approach to Laparoscopic Myomectomy Lang TG,1 Shiber L-D,1 Dassel M,2 Pasic R.1 1Ob/Gyn MInimally Invasive Gynecologic Surgery, University of Louisville School of Medicine, Louisville, Kentucky; 2OB/GYN, The University of Utah School of Medicine, Salt Lake City, Utah
Single port laparoscopic surgery for huge ovarian cyst In case of huge ovarian tumor, physicians should consider how to remove it without spillage. So it is hard to do laparoscopy in such a case because the pelvic cavity is narrow and difficult to keep the ovarian mass intact until removal. In this video, we show two cases of huge ovarian tumor doing single port laparoscopic hysterectomy with unilateral/bilateral salpingooophorectomy with SW KIM’s method. SW KIM’s method is the technique to put huge ovarian tumor into the endopouch using specially designed (30x30cm2 sized) endopouch, two conventional laparoscopic needle holders and one laparoscopic grasper. The key point of SW KIM’s method is to remove ovarian tumor without spillage in a single port laparoscopic surgery by putting it into the large endoscopic bag despite narrow space. 705
For patients with symptomatic fibroids and/or infertility who have not completed childbearing, myomectomy is often an option. The laparoscopic approach to myomectomy provides patients with a more rapid recovery and decreased length of hospital stay, as well as equivalent clinical outcomes in comparison to an open procedure. This film presents a technique for laparoscopic myomectomy. A series of steps are demonstrated with surgical footage and detailed discussion, including techniques for hemostasis, dissection using the Harmonic scalpel, chromotubation, layered closure and morcellation. 702 Difficult Uteruses: Tips to Manage Total Laparoscopic Hysterectomy in Patients with Multiple Laparotomies Lawande A, Desai R, Hosamani G, Puntambekar SP. Galaxy Care Laparoscopy Institute, Pune, Maharashtra, India In this video we demonstrate difficult total laparoscopic hysterectomies in patients with previous laparotomies. Tips to tackle these situations and manage laparoscopically without complications or conversion. These were the situations: 1) In post whipple’s procedure - Multiple adhesions of bowel to anterior abdominal wall. 2) Previous 3 LSCS - Uterus firmly plastered to anterior abdominal wall. 3) Following previous 3 laparoscopies and 1 laparotomy in stage IV endometriosis- Loss of pelvic anatomy 4)Previous 2 LSCS - Bladder badly stuck to uterus. Using our oncosurgical experience, sound laparoscopy principles and anatomical knowledge we managed to tackle these situations without conversion. 703 Single Port Laparoscopic Myomectomy Using YS Knot Lee YS, Chong GO, Lee YH, Hong DG. Gynecologic Cancer Center, Kyungpook National University Medical Center, Daegu, Republic of Korea This video demonstrates a single port laparoscopic myomectomy using YS Knot. YS Knot is extracorporeal sliding knot. The advantages of YS Knot are simple, fast, easy to learn and no slip after knot. After vasopressin injection, oblique uterine incision was made, and myoma was enucleated. Traction suture at uterus was done through abdominal wall, and endometrial defect was closed with interrupted suture (1st layer). Myometrial defect was closed by multiple interrupted suture (2nd layer). Horizontal mattress traction suture was made using Hem-o-lok (3rd layer). Seromuscular layer was closed by multiple interrupted suture using YS Knot (4th layer). YS Knot may contribute to overcome the difficulty of intracorporeal suture during single port myomectomy.
Laparoscopic Radical Hysterectomy Liu X, Jiang H. Obstetrics and Gyncology Hospital of Fudan University, Shanghai, China Under general anesthesia, the patient was put in a lithotomy-Trendelenburg position. A 10-mm trocar was introduced through the umbilicus, and the abdominal cavity was insufflated with carbon dioxide and explored for evidence of metastatic disease.One pair of 5-mm trocars was placed symmetrically approximately 4 cm away from the umbilicus, slightly below the horizontal line passing through the umbilicus. Another pair of trocars, one 5 mm and the other 10 mm, was inserted bilaterally at the outer one-third of the iliac spine umbilicus line symmetrically. 706 Laparoscopic Resection of a Retroperitoneal Liposarcoma Liu GY, Kung RC. Obstetrics and Gynaecology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada Thank you for giving us the opportunity to present a surgical video of a laparoscopic resection of a retroperitoneal liposarcoma. This 56 year old presented with an enlarging abdominal mass in 2010. Her symptoms included increasing bladder and rectal pressure and a rectal prolapse. Her colonoscopy was normal. She previously had an abdominal myomectomy in 2008, and given this history as well as imaging consistent with a recurrent fibroid, she was consented for a laparoscopic myomectomy. Because the mass extended to the umbilicus and she previously had a ventral hernia repair repaired with mesh, a Palmer’s point entry was performed. The mass was free from the uterus and cervix, and was close to the sigmoid mesentery. Her postoperative course was complicated by a bowel perforation secondary to an obstructive mass in her sigmoid colon. The pathology on both masses returned as liposarcoma. 707 Laparoscopic Concealed Uterine Morcellation Mattingly P, Taylor B. Obstetrics and Gynecology, Carolinas Medical Center, Charlotte, North Carolina This video illustrates a concealed laparoscopic morcellation technique using an endoscopic isolation bag to remove an 800 gm uterus after a laparoscopic supracervical hysterectomy. The FDA has released a statement discouraging open laparoscopic power morcellation because of the concern for spreading an undiagnosed malignancy. The purpose of this video is to demonstrate a technique to perform concealed tissue extraction via power morcellation endoscopically. 708
704 Single Port Accessed Laparoscopic Surgery of Huge Ovarian Tumors Lee J, Yim GW, Nam EJ, Kim S, Kim YT, Kim SW. Obstetrics and Gynecology, Yonsei University College of Medicine, Seoul, Korea
Failed Mesh Sacral Colpopexy Resulting in Recurrent Uterine Prolapse Treated Successfully with Laparoscopic Sacral Colpohysteropexy Miklos JR, Moore RD, Chinthakanan O. International Urogynecology Associates, Alpharetta (Atlanta), Georgia
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This video demonstrates how total laparoscopic hysterectomy of a large voluminous fibroid uterus can be achieved by using instruments and techniques that help improve visualization and accomplish safe dissection. 697 Single Port Para Aortic Lymphadenectomy: Tips and Tricks Jennings AJ, Al-Niaimi A. Department of Ob/Gyn, University of Wisconsin, Madison, Wisconsin This video displays three recommended surgical tips to help optimize para aortic lymphadenectomy using Single Port Laparoscopy. The video begins with the standard entry into the abdomen. Visualization of the techniques, as well as reminders of pelvic anatomy are provided. In addition, the video focuses on the unique challenges caused by a patient’s obesity and ways to improve visualization in those circumstances. 698 Laparoscopic Myomectomy with New Vaginal Morcellation Kim D, Byon M, Kim H. Chung-ang University Hospital, Seoul, Korea The introduction of electomechanical morcellation reduced the procedure time, but still morcellation is the most time-consuming part of the entire procedure in the cases of huge mass. Especially when removing a huge uterine mass, we believe a morcellator with a diameter of 20 mm is the most suitable but it will create a large scar, roughly the size of morcellator being applied. Bigger sized morcellator is preferred to avoid prolongation of operation time, but accompanied additional skin incision which causes more post-operative pain and less cosmetic effect, does not correspond to the requirements of minimally invasive surgery. we carried out morcellation by the vaginal route using Semm’s morcellation sets. Thus, vaginal morcellation could be an easy way to overcome the limit and strengthen the laparoscopic operation. With this technique, there is no need to enlarge any of the abdominal port sites to accommodate the morcellator.
695
699
Robotic Single-Port Hysterectomy Gungor M, Ozbasli E, Kahraman K, Genim C. Obstetrics and Gynecology Department, Acibadem University, Faculty of Medicine, Istanbul, Turkey
Laparoscopic Preconceptional Transabdominal Cervico-Isthmic Cerclage (TCIC) Koh AR,1 Choi JS,1 Bae J,1 Lee WM,1 Ko JH,2 Ju W.3 1Hanyang University College of Medicine, Seoul, Republic of Korea; 2Kangwon National University Hospital, Chuncheon, Gangwon-do, Republic of Korea; 3Ewha Womans University School of Medicine, Seoul, Republic of Korea
Background/Hypothesis: Single- port robotic surgery is a promising surgical frontier Methods and Materials: The video shows a case of single-port robot assisted hysterectomy that was performed to a 53- year old patient who has a body mass index of 39. The indication was postmenopausal bleeding and leiomyoma. Results: The operation time was 60 minutes. The bleeding was 100 cc. No intraoperative and postoperative complication was observed. The patient was discharged on postoperative day 1 with no problem. Conclusion: Single- port robotic surgery has better cosmesis, minimizes the potential morbidity, decreases postoperative analgesia and has a shorter convalescence period. More prospective studies are needed. 696 Tips and Surgical Technique for Minimally Invasive Hysterectomy in a Patient with Massive Fibroid Uterus Jan A,1 Campian C,2 Tatalovich J.3 1Ob/Gyn, Medstar Franklin Square Hospital Center, Baltimore, Maryland; 2Urogynecology, St. Louis University, St. Louis, Missouri; 3Urogynecology, Heritage Medical Associates, Nashville, Tennessee T.K. is a 52 year old female with a BMI of 42 who presented to the hospital with pelvic pain and was found to have a massive fibroid uterus measuring approximately 32-35 cm. The patient strongly desired minimally invasive surgery and delayed surgery for many years from fear of laparotomy.
A 33-year-old Korean woman underwent laparoscopic radical trachelectomy, bilateral laparoscopic pelvic lymphadenectomy, and transvaginal cerclage using a Ethibond in 2008. The final histopathological report showed squamous cell carcinoma confined to the uterine cervix, with the maximum size of 9mm and no lymph node metastasis. She was referred to our clinic due to recurrent midtrimester miscarriages and anatomical cause of incompetent cervix. We performed laparoscopic preconceptional transabdominal cerclage using a 5mm Mersilene band on the avascular space, between the uterine arteries and bifurcation of the ascending branch, at the level of uterine cervicoisthmic junction. 700 Go Retro: When the Going Gets Tough Go Retroperitoneal Kondrup JD, Sylvester BA, Branning ML. Lourdes Hospital, 169 Riverside Drive, Binghamton, New York As I teach MIGS courses around the world I find that many laparoscopic surgeons are intimidated by entering the retroperitioneal space to either dissect out the ureter or ligate the uterine artery at its origin. The gynecologic oncologist feels very comfortable here and enters this space
S220
Abstracts / Journal of Minimally Invasive Gynecology 21 (2014) S191–S227
immediately during oncology surgery. This video demonstrates how to enter the retroperioneal space for gynecologists and to locate the ureter and the uterine artery. It illustrates easy steps and ends with a difficult case showing the technique of dissection. The laparoscopic GYN surgeon will find this video helpful in getting started in entering this space. We say, ‘‘When the going gets tough; GO RETRO.’’ 701 A Systematic Approach to Laparoscopic Myomectomy Lang TG,1 Shiber L-D,1 Dassel M,2 Pasic R.1 1Ob/Gyn MInimally Invasive Gynecologic Surgery, University of Louisville School of Medicine, Louisville, Kentucky; 2OB/GYN, The University of Utah School of Medicine, Salt Lake City, Utah
Single port laparoscopic surgery for huge ovarian cyst In case of huge ovarian tumor, physicians should consider how to remove it without spillage. So it is hard to do laparoscopy in such a case because the pelvic cavity is narrow and difficult to keep the ovarian mass intact until removal. In this video, we show two cases of huge ovarian tumor doing single port laparoscopic hysterectomy with unilateral/bilateral salpingooophorectomy with SW KIM’s method. SW KIM’s method is the technique to put huge ovarian tumor into the endopouch using specially designed (30x30cm2 sized) endopouch, two conventional laparoscopic needle holders and one laparoscopic grasper. The key point of SW KIM’s method is to remove ovarian tumor without spillage in a single port laparoscopic surgery by putting it into the large endoscopic bag despite narrow space. 705
For patients with symptomatic fibroids and/or infertility who have not completed childbearing, myomectomy is often an option. The laparoscopic approach to myomectomy provides patients with a more rapid recovery and decreased length of hospital stay, as well as equivalent clinical outcomes in comparison to an open procedure. This film presents a technique for laparoscopic myomectomy. A series of steps are demonstrated with surgical footage and detailed discussion, including techniques for hemostasis, dissection using the Harmonic scalpel, chromotubation, layered closure and morcellation. 702 Difficult Uteruses: Tips to Manage Total Laparoscopic Hysterectomy in Patients with Multiple Laparotomies Lawande A, Desai R, Hosamani G, Puntambekar SP. Galaxy Care Laparoscopy Institute, Pune, Maharashtra, India In this video we demonstrate difficult total laparoscopic hysterectomies in patients with previous laparotomies. Tips to tackle these situations and manage laparoscopically without complications or conversion. These were the situations: 1) In post whipple’s procedure - Multiple adhesions of bowel to anterior abdominal wall. 2) Previous 3 LSCS - Uterus firmly plastered to anterior abdominal wall. 3) Following previous 3 laparoscopies and 1 laparotomy in stage IV endometriosis- Loss of pelvic anatomy 4)Previous 2 LSCS - Bladder badly stuck to uterus. Using our oncosurgical experience, sound laparoscopy principles and anatomical knowledge we managed to tackle these situations without conversion. 703 Single Port Laparoscopic Myomectomy Using YS Knot Lee YS, Chong GO, Lee YH, Hong DG. Gynecologic Cancer Center, Kyungpook National University Medical Center, Daegu, Republic of Korea This video demonstrates a single port laparoscopic myomectomy using YS Knot. YS Knot is extracorporeal sliding knot. The advantages of YS Knot are simple, fast, easy to learn and no slip after knot. After vasopressin injection, oblique uterine incision was made, and myoma was enucleated. Traction suture at uterus was done through abdominal wall, and endometrial defect was closed with interrupted suture (1st layer). Myometrial defect was closed by multiple interrupted suture (2nd layer). Horizontal mattress traction suture was made using Hem-o-lok (3rd layer). Seromuscular layer was closed by multiple interrupted suture using YS Knot (4th layer). YS Knot may contribute to overcome the difficulty of intracorporeal suture during single port myomectomy.
Laparoscopic Radical Hysterectomy Liu X, Jiang H. Obstetrics and Gyncology Hospital of Fudan University, Shanghai, China Under general anesthesia, the patient was put in a lithotomy-Trendelenburg position. A 10-mm trocar was introduced through the umbilicus, and the abdominal cavity was insufflated with carbon dioxide and explored for evidence of metastatic disease.One pair of 5-mm trocars was placed symmetrically approximately 4 cm away from the umbilicus, slightly below the horizontal line passing through the umbilicus. Another pair of trocars, one 5 mm and the other 10 mm, was inserted bilaterally at the outer one-third of the iliac spine umbilicus line symmetrically. 706 Laparoscopic Resection of a Retroperitoneal Liposarcoma Liu GY, Kung RC. Obstetrics and Gynaecology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada Thank you for giving us the opportunity to present a surgical video of a laparoscopic resection of a retroperitoneal liposarcoma. This 56 year old presented with an enlarging abdominal mass in 2010. Her symptoms included increasing bladder and rectal pressure and a rectal prolapse. Her colonoscopy was normal. She previously had an abdominal myomectomy in 2008, and given this history as well as imaging consistent with a recurrent fibroid, she was consented for a laparoscopic myomectomy. Because the mass extended to the umbilicus and she previously had a ventral hernia repair repaired with mesh, a Palmer’s point entry was performed. The mass was free from the uterus and cervix, and was close to the sigmoid mesentery. Her postoperative course was complicated by a bowel perforation secondary to an obstructive mass in her sigmoid colon. The pathology on both masses returned as liposarcoma. 707 Laparoscopic Concealed Uterine Morcellation Mattingly P, Taylor B. Obstetrics and Gynecology, Carolinas Medical Center, Charlotte, North Carolina This video illustrates a concealed laparoscopic morcellation technique using an endoscopic isolation bag to remove an 800 gm uterus after a laparoscopic supracervical hysterectomy. The FDA has released a statement discouraging open laparoscopic power morcellation because of the concern for spreading an undiagnosed malignancy. The purpose of this video is to demonstrate a technique to perform concealed tissue extraction via power morcellation endoscopically. 708
704 Single Port Accessed Laparoscopic Surgery of Huge Ovarian Tumors Lee J, Yim GW, Nam EJ, Kim S, Kim YT, Kim SW. Obstetrics and Gynecology, Yonsei University College of Medicine, Seoul, Korea
Failed Mesh Sacral Colpopexy Resulting in Recurrent Uterine Prolapse Treated Successfully with Laparoscopic Sacral Colpohysteropexy Miklos JR, Moore RD, Chinthakanan O. International Urogynecology Associates, Alpharetta (Atlanta), Georgia