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Robotic Single-Incision Ovarian Vein Ligation for Pelvic Congestion Syndrome
S154
Abstracts / Journal of Minimally Invasive Gynecology 22 (2015) S1–S253
553
557
Robotic Single-Incision Ovarian Vein Ligation for Pelvic Congestion Syndrome Xiaoming G, Walsh TM, Hernandez A, Osial P, Xu D. Department of Ob/ Gyn, Baylor College of Medicine, Houston, Texas
Robotic-Assisted Removal of Transvaginal Mesh, a Minimally-Invasive Approach Williams KS,1 Shalom DF,1 Hill JR,2 Winkler HA,1 Finamore PS.3 1 Female Pelvic Medicine and Reconstructive Surgery, North Shore-LIJ Health System, Great Neck, New York; 2Urology, Smith Institute for Urology, Suffolk County, Hauppauge, New York; 3Female Pelvic Medicine and Reconstructive Surgery, North Shore-LIJ Health System, Hauppauge, New York
We present a case of robotic single-incision ovarian vein ligation for a patient with pelvic congestion syndrome. Robotic single-site site surgery has minor limitations compared to multi-port robotic surgery. While it continues to have the benefits of excellent 3D visualization, the robotic-single site instruments have decreased range of motion and do not yet have the ability to articulate which requires minor changes to surgical technique. Indocyanine green was used to assist in identification of the pelvic vasculature. In this video we highlight that despite minor technology limitations, single-site robotic technology is still able to perform very fine dissections. 554 Robot-Assisted Laparoscopic Repair of a Cesarean Scar Defect With Hysteroscopic Guidance Robinson E, Yunker A. Vanderbilt University Medical Center, Nashville, Tennessee In this video, we demonstrate a surgical approach to repair a uterine defect due to prior cesarean section. As this is an emerging concern with increased cesarean section rates, our goal is to demonstrate a safe, effective, and minimally invasive approach to repair these defects. In this video, hysteroscopy is used to identify the defect. Then, through a robot-assisted laparoscopic technique, a hysterotomy is made and the defect repaired in two layers. Preoperative and postoperative MRI demonstrates the effectiveness of this repair. This patient was discharged home the same day. While secondary infertility was a complaint preoperatively, she has been able to achieve pregnancy since the repair. 555 Advanced Robotics: Removal of a 25cm Pelvic Mass Fornalik H,1 Fornalik N,1 Kincy T.2 1Department of Gynecologic Oncology, St. Vincent Hospital, Indianapolis, Indiana; 2Obstetrics and Gynecology Residency, St. Vincent Women’s Hospital, Indianapolis, Indiana This is a video presentation demonstrating surgical technique and removal of a large pelvic mass with minimally invasive surgery. In the video, we demonstrate how small, precise movements with careful dissection are needed to define the anatomy. We also show how the skeletonization of enlarged pedicles and the use of hemalock clips and sliding knots can minimize bleeding-a key step, as excessive bleeding can obscure already distorted anatomy. Placement of a large isolation bag through the vagina, which is covered with a wound protector to prevent bacterial seeding, allows the mass to be removed through a small hand assisted abdominal site. Through the use of a trained bedside assistant, an experienced anesthesiologist, the uterine manipulator and the 4th robotic arm, it is possible to remove large pelvic masses using minimally invasive surgical techniques. 556 2-Incision Single-Site + 1 Robotic Sacrocolpopexy Salvay H. Ob/Gyn, Palo Alto Medical Foundation, Santa Cruz, California This 2 incision Single-Site Plus 1 Sacrocolpopexy demonstrates the feasibility to perform advanced Minimally Invasive Surgery with the daVinci Single-Site platform by adding an additional standard robotic arm. Comparable operative times without complications in 4 consecutive patients with Stage 3 prolapse shows the utility of this approach to provide an advantage over traditional laparoscopic surgery.
Patients with trans-vaginal mesh (TVM) complications commonly present with mesh exposure and pain. Multiple surgeries are often required for complete TVM excision and symptom resolution. In patients with a history of failed vaginal attempts at TVM excision, Robotic-assisted laparoscopy offers an effective yet minimally invasive approach to mesh excision. We present a 55-year-old with persistent mesh exposure despite 4 vaginal excision attempts. For robotic-assisted removal of TVM, a Martin arm deviates the vaginal walls, cervix and uterus. A bladder flap is dissected off the anterior vaginal wall. Intraoperative vaginal exam by an assistant locates TVM margins which are grasped at the corresponding intra-abdominal location using robotic Maryland forceps. Tension on TVM helps visualize and excise TVM arms. Intraoperative vaginal exam confirms total TVM excision and resolution of banding appreciated on preoperative physical exam. Robotic-assisted excision of TVM is a useful approach for patients after failed vaginal TVM excision. 558 Robotic Single-Site Surgery in Gynecology: Advantages and Pitfalls El Hachem L, Barr R, Mathews S, Chuang LC, Gretz HF. Minimally Invasive Gynecology, Icahn School of Medicine at Mount Sinai, New York, New York Robotic single-site surgery was developed in the continued effort of improving cosmesis and reducing morbidity. Despite the introduction of the robotic interface in single-site surgery and the development of specialized instruments, the performance of complex procedures has been challenging. This video illustrates some of the pitfalls of robotic single-site surgery including a larger incision, instrument crowding and clashing. By demonstrating the different steps of a robotic single site hysterectomy, tips are given to overcome some of the technical limitations of the current array of instruments. Careful case selection and awareness of pitfalls will improve clinical outcomes. 559 Case Report: Place of Trans-Abdominal Cerclage Using the da Vinci Robotic System in Infertility Patients With Incompetent Cervix Fahmi I,1 Raju R,1 DeAnna J,2 Thakur M,3 Pugmire D,4 Ashraf M,1 Abuzeid MI.1 1Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Hurley Medical Center/ Michigan State University College of Human Medicine, Flint, Michigan; 2 Department of Obstetrics and Gynecology, Genesys Regional Medical Center, Grand Blanc, Michigan; 3Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Detroit Medical Center/Wayne State University, Detroit, Michigan; 4Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Crittenton Hospital, Rochester Hills, Michigan Cerclage is the main surgical approach to cervical insufficiency which can either be trans-vaginally or trans-abdominally. Trans-abdominal cerclage can be placed via laparotomy or laparoscopy or robotic-assisted laparoscopic surgery (RALS). 39 yo female G3P1L0 presented with primary infertility was found to have a uterine septum which was corrected then conceived via Assisted Reproductive Technology. A trans-vaginal cerclage was
Abstracts / Journal of Minimally Invasive Gynecology 22 (2015) S1–S253
553
557
Robotic Single-Incision Ovarian Vein Ligation for Pelvic Congestion Syndrome Xiaoming G, Walsh TM, Hernandez A, Osial P, Xu D. Department of Ob/ Gyn, Baylor College of Medicine, Houston, Texas
Robotic-Assisted Removal of Transvaginal Mesh, a Minimally-Invasive Approach Williams KS,1 Shalom DF,1 Hill JR,2 Winkler HA,1 Finamore PS.3 1 Female Pelvic Medicine and Reconstructive Surgery, North Shore-LIJ Health System, Great Neck, New York; 2Urology, Smith Institute for Urology, Suffolk County, Hauppauge, New York; 3Female Pelvic Medicine and Reconstructive Surgery, North Shore-LIJ Health System, Hauppauge, New York
We present a case of robotic single-incision ovarian vein ligation for a patient with pelvic congestion syndrome. Robotic single-site site surgery has minor limitations compared to multi-port robotic surgery. While it continues to have the benefits of excellent 3D visualization, the robotic-single site instruments have decreased range of motion and do not yet have the ability to articulate which requires minor changes to surgical technique. Indocyanine green was used to assist in identification of the pelvic vasculature. In this video we highlight that despite minor technology limitations, single-site robotic technology is still able to perform very fine dissections. 554 Robot-Assisted Laparoscopic Repair of a Cesarean Scar Defect With Hysteroscopic Guidance Robinson E, Yunker A. Vanderbilt University Medical Center, Nashville, Tennessee In this video, we demonstrate a surgical approach to repair a uterine defect due to prior cesarean section. As this is an emerging concern with increased cesarean section rates, our goal is to demonstrate a safe, effective, and minimally invasive approach to repair these defects. In this video, hysteroscopy is used to identify the defect. Then, through a robot-assisted laparoscopic technique, a hysterotomy is made and the defect repaired in two layers. Preoperative and postoperative MRI demonstrates the effectiveness of this repair. This patient was discharged home the same day. While secondary infertility was a complaint preoperatively, she has been able to achieve pregnancy since the repair. 555 Advanced Robotics: Removal of a 25cm Pelvic Mass Fornalik H,1 Fornalik N,1 Kincy T.2 1Department of Gynecologic Oncology, St. Vincent Hospital, Indianapolis, Indiana; 2Obstetrics and Gynecology Residency, St. Vincent Women’s Hospital, Indianapolis, Indiana This is a video presentation demonstrating surgical technique and removal of a large pelvic mass with minimally invasive surgery. In the video, we demonstrate how small, precise movements with careful dissection are needed to define the anatomy. We also show how the skeletonization of enlarged pedicles and the use of hemalock clips and sliding knots can minimize bleeding-a key step, as excessive bleeding can obscure already distorted anatomy. Placement of a large isolation bag through the vagina, which is covered with a wound protector to prevent bacterial seeding, allows the mass to be removed through a small hand assisted abdominal site. Through the use of a trained bedside assistant, an experienced anesthesiologist, the uterine manipulator and the 4th robotic arm, it is possible to remove large pelvic masses using minimally invasive surgical techniques. 556 2-Incision Single-Site + 1 Robotic Sacrocolpopexy Salvay H. Ob/Gyn, Palo Alto Medical Foundation, Santa Cruz, California This 2 incision Single-Site Plus 1 Sacrocolpopexy demonstrates the feasibility to perform advanced Minimally Invasive Surgery with the daVinci Single-Site platform by adding an additional standard robotic arm. Comparable operative times without complications in 4 consecutive patients with Stage 3 prolapse shows the utility of this approach to provide an advantage over traditional laparoscopic surgery.
Patients with trans-vaginal mesh (TVM) complications commonly present with mesh exposure and pain. Multiple surgeries are often required for complete TVM excision and symptom resolution. In patients with a history of failed vaginal attempts at TVM excision, Robotic-assisted laparoscopy offers an effective yet minimally invasive approach to mesh excision. We present a 55-year-old with persistent mesh exposure despite 4 vaginal excision attempts. For robotic-assisted removal of TVM, a Martin arm deviates the vaginal walls, cervix and uterus. A bladder flap is dissected off the anterior vaginal wall. Intraoperative vaginal exam by an assistant locates TVM margins which are grasped at the corresponding intra-abdominal location using robotic Maryland forceps. Tension on TVM helps visualize and excise TVM arms. Intraoperative vaginal exam confirms total TVM excision and resolution of banding appreciated on preoperative physical exam. Robotic-assisted excision of TVM is a useful approach for patients after failed vaginal TVM excision. 558 Robotic Single-Site Surgery in Gynecology: Advantages and Pitfalls El Hachem L, Barr R, Mathews S, Chuang LC, Gretz HF. Minimally Invasive Gynecology, Icahn School of Medicine at Mount Sinai, New York, New York Robotic single-site surgery was developed in the continued effort of improving cosmesis and reducing morbidity. Despite the introduction of the robotic interface in single-site surgery and the development of specialized instruments, the performance of complex procedures has been challenging. This video illustrates some of the pitfalls of robotic single-site surgery including a larger incision, instrument crowding and clashing. By demonstrating the different steps of a robotic single site hysterectomy, tips are given to overcome some of the technical limitations of the current array of instruments. Careful case selection and awareness of pitfalls will improve clinical outcomes. 559 Case Report: Place of Trans-Abdominal Cerclage Using the da Vinci Robotic System in Infertility Patients With Incompetent Cervix Fahmi I,1 Raju R,1 DeAnna J,2 Thakur M,3 Pugmire D,4 Ashraf M,1 Abuzeid MI.1 1Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Hurley Medical Center/ Michigan State University College of Human Medicine, Flint, Michigan; 2 Department of Obstetrics and Gynecology, Genesys Regional Medical Center, Grand Blanc, Michigan; 3Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Detroit Medical Center/Wayne State University, Detroit, Michigan; 4Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Crittenton Hospital, Rochester Hills, Michigan Cerclage is the main surgical approach to cervical insufficiency which can either be trans-vaginally or trans-abdominally. Trans-abdominal cerclage can be placed via laparotomy or laparoscopy or robotic-assisted laparoscopic surgery (RALS). 39 yo female G3P1L0 presented with primary infertility was found to have a uterine septum which was corrected then conceived via Assisted Reproductive Technology. A trans-vaginal cerclage was