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Isthmocele Repair: Robotic-Assisted Laparoscopy with Simultaneous Hysteroscopy
Abstracts / Journal of Minimally Invasive Gynecology 26 (2019) S1−S97 Plenary 8: Robotics (4:10 PM − 5:10 PM) 4:40 PM Robotic Interval Cytoreductive Surgery for Stage IV Epithelial Ovarian Cancer Mutlu L,1 Khadraoui W,2,* Kim S,3 Menderes G1. 1Obstetrics, Gynecology & Reproductive Sciences, Yale School of Medicine, New Haven, CT; 2 Obstetrics and Gynecology, Yale New Haven Health, Bridgeport Hospital, Bridgeport, CT; 3Yale, New Haven Hospital, New Haven, CT *Corresponding author. Video Objective: To demonstrate a surgical video where-in interval cytoreduction to no gross residual disease was performed robotically in a patient with Stage IV epithelial ovarian cancer. Setting: Tertiary referral center. Interventions: 43-year-old Caucasian female was diagnosed with stage IV-A high-grade serous ovarian adenocarcinoma after presenting with shortness of breath. Computed tomography showed bilateral pleural effusions, adnexal masses, retroperitoneal lymphadenopathy, omental caking. Thoracentesis confirmed adenocarcinoma of Mullerian primary. She received three cycles of neoadjuvant carboplatinum and paclitaxel with excellent clinical response and was taken to the operating room for robotic-assisted interval cytoreductive surgery. Trocars were placed on a straight horizontal line along the umbilical fold. The rectosigmoid colon was mobilized medially. Pararectal and paravesical spaces were developed. Ureterolysis was completed bilaterally. The uterine vessels were sealed at the hypogastric bifurcation. Infundibulopelvic (IP) ligament was sealed and cut. Bilateral pelvic sidewall peritoneum was resected. Bladder flap was developed. Colpotomy was performed and the hysterectomy specimen was removed. Procedure was then continued with debulking of enlarged lymph nodes, from bilateral pelvic sidewalls and peri-aortic area. The robotic arms were targeted to the upper abdomen for total omentectomy. Access to the lesser sac was gained by resecting short gastic vessels, along the greater curvature of the stomach. The incision was then extended to the splenic flexure and hepatic flexure. Total omentectomy was completed. Remaining subcentimeter tumoral nodules along the peritoneal surfaces were ablated with argon beam coagulator. The patient had an uneventful postoperative course and was discharged home on postoperative day 1. Pathology confirmed high grade serous ovarian carcinoma. She was resumed on chemotherapy two weeks after her cytoreductive surgery. Conclusion: Laparoscopic/robotic interval cytoreductive surgery should be considered in advanced ovarian cancer patients, who have an excellent clinical response to NACT. Studies to accurately identify the appropriate patient population for laparoscopic/robotic debulking procedures are urgently encouraged and needed. Plenary 8: Robotics (4:10 PM − 5:10 PM) 4:50 PM Isthmocele Repair: Robotic-Assisted Laparoscopy with Simultaneous Hysteroscopy Seaman SJ,1,* Arora C,2 Advincula AP2. 1Obstetrics and Gynecology, Columbia University Irving Medical Center - New York Presbyterian Hospital, New York, NY; 2Obstetrics and Gynecology, Columbia University Medical Center, New York, NY *Corresponding author. Video Objective: To illustrate the use of robotic-assisted laparoscopy with simultaneous hysteroscopy for the repair of an isthmocele. Setting: An isthmocele is a pouch-like anterior uterine wall defect at the site of a previous cesarean scar. The incidence is not well known but is estimated in the literature is between 19 and 88%. Complications arising from an isthmocele may include abnormal uterine
S17 bleeding (especially postmenstrual bleeding), abdominal pain, diminished fertility, ectopic pregnancy, or obstetric complications such as uterine rupture. Repair of isthmocele may be indicated for symptomatic relief and preservation of fertility. Multiple surgical approaches have been described in the literature including laparoscopic, hysteroscopic, and vaginal approaches. Interventions: In this video, we illustrate the key surgical steps of roboticassisted laparoscopy with simultaneous hysteroscopic guidance for the repair of an isthmocele. Key surgical steps include: 1. Pre-surgical planning with MRI 2. Diagnostic hysteroscopy for confirmation of isthmocele 3. Simultaneous laparoscopy for identification of borders 4. Strategic hysterotomy 5. Excision of scar tissue 6. Tension-free closure Conclusion: Robotic-assisted laparoscopy with simultaneous hysteroscopy is a feasible and safe approach for the repair of an isthmocele. Plenary 8: Robotics (4:10 PM − 5:10 PM) 5:00 PM Increased Same Day Discharge Rate After Laparoscopic Guided 4-Point Transversus Abdominis Plane Block for Robotic Assisted Gynecologic Procedures Ladanyi C,1,* Sticco PL,1 Blevins M,2 Boyd S,2 Gutmann D,3 Holcombe J,4 Mohling S5. 1Minimally Invasive Gynecologic Surgery, University of Tennessee College of Medicine Chattanooga, Chattanooga, TN; 2 Obstetrics and Gynecology, University of Tennessee, College of Medicine, Chattanooga, TN; 3Emergency Department, Erlanger Hospital, University of Tennessee, College of Medicine, Chattanooga, TN; 4 University of Tennessee, School of Nursing & School of Education, Chattanooga, TN; 5Obstetrics and Gynecology, Minimally Invasive Gynecology, University of Tennessee, College of Medicine, Chattanooga, TN *Corresponding author. Study Objective: To compare rates of same day discharge between fourpoint and two-point, laparoscopically guided transversus abdominis plane (TAP) blocks, for robotic-assisted gynecologic procedures. Design: We performed a retrospective chart review from October 2017 to March 2019. All information from the surgical admission as well as postoperative follow up was reviewed. Data was compared to a similar cohort of patients who had received two-point TAP blocks. Setting: All procedures were performed at one academic hospital. Patients or Participants: 116 patients who underwent robotic-assisted gynecologic surgery, with administration of a four-point TAP block were included. Interventions: A four-point TAP block was performed under laparoscopic visualization by the same surgeon after induction of anesthesia and immediately following placement of the laparoscope. 20 mL of Liposomal bupivacaine and 20 mL of 0.5% bupivacaine mixed with saline were used as the injectate for both groups. Measurements and Main Results: 116 patients were included with a mean age of 40.6 (19-80) and a mean body mass index of 30.6 (17.2-53.3). 70.7 % of patients were discharged to home on the day of surgery. Of the 29.3% of patients who were admitted 20.6 % were due to pain control. Those who were admitted for pain control comprised 6.0% of all study participants. In the cohort who received the two-point TAP block, only 33.7% of patients were discharged home on the day of surgery which was significantly lower than the four-point cohort with a p value of < 0.001. There were no adverse events in either group. Conclusion: A surgeon performed TAP block, under laparoscopic visualization, is a safe and efficacious intervention to reduce postoperative pain thereby increasing same day discharge rate. In this study, patients who received a four-point TAP block had a higher rate of same-day discharge than those in the group who received the two-point TAP.
S17 bleeding (especially postmenstrual bleeding), abdominal pain, diminished fertility, ectopic pregnancy, or obstetric complications such as uterine rupture. Repair of isthmocele may be indicated for symptomatic relief and preservation of fertility. Multiple surgical approaches have been described in the literature including laparoscopic, hysteroscopic, and vaginal approaches. Interventions: In this video, we illustrate the key surgical steps of roboticassisted laparoscopy with simultaneous hysteroscopic guidance for the repair of an isthmocele. Key surgical steps include: 1. Pre-surgical planning with MRI 2. Diagnostic hysteroscopy for confirmation of isthmocele 3. Simultaneous laparoscopy for identification of borders 4. Strategic hysterotomy 5. Excision of scar tissue 6. Tension-free closure Conclusion: Robotic-assisted laparoscopy with simultaneous hysteroscopy is a feasible and safe approach for the repair of an isthmocele. Plenary 8: Robotics (4:10 PM − 5:10 PM) 5:00 PM Increased Same Day Discharge Rate After Laparoscopic Guided 4-Point Transversus Abdominis Plane Block for Robotic Assisted Gynecologic Procedures Ladanyi C,1,* Sticco PL,1 Blevins M,2 Boyd S,2 Gutmann D,3 Holcombe J,4 Mohling S5. 1Minimally Invasive Gynecologic Surgery, University of Tennessee College of Medicine Chattanooga, Chattanooga, TN; 2 Obstetrics and Gynecology, University of Tennessee, College of Medicine, Chattanooga, TN; 3Emergency Department, Erlanger Hospital, University of Tennessee, College of Medicine, Chattanooga, TN; 4 University of Tennessee, School of Nursing & School of Education, Chattanooga, TN; 5Obstetrics and Gynecology, Minimally Invasive Gynecology, University of Tennessee, College of Medicine, Chattanooga, TN *Corresponding author. Study Objective: To compare rates of same day discharge between fourpoint and two-point, laparoscopically guided transversus abdominis plane (TAP) blocks, for robotic-assisted gynecologic procedures. Design: We performed a retrospective chart review from October 2017 to March 2019. All information from the surgical admission as well as postoperative follow up was reviewed. Data was compared to a similar cohort of patients who had received two-point TAP blocks. Setting: All procedures were performed at one academic hospital. Patients or Participants: 116 patients who underwent robotic-assisted gynecologic surgery, with administration of a four-point TAP block were included. Interventions: A four-point TAP block was performed under laparoscopic visualization by the same surgeon after induction of anesthesia and immediately following placement of the laparoscope. 20 mL of Liposomal bupivacaine and 20 mL of 0.5% bupivacaine mixed with saline were used as the injectate for both groups. Measurements and Main Results: 116 patients were included with a mean age of 40.6 (19-80) and a mean body mass index of 30.6 (17.2-53.3). 70.7 % of patients were discharged to home on the day of surgery. Of the 29.3% of patients who were admitted 20.6 % were due to pain control. Those who were admitted for pain control comprised 6.0% of all study participants. In the cohort who received the two-point TAP block, only 33.7% of patients were discharged home on the day of surgery which was significantly lower than the four-point cohort with a p value of < 0.001. There were no adverse events in either group. Conclusion: A surgeon performed TAP block, under laparoscopic visualization, is a safe and efficacious intervention to reduce postoperative pain thereby increasing same day discharge rate. In this study, patients who received a four-point TAP block had a higher rate of same-day discharge than those in the group who received the two-point TAP.