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Safety of Left Upper Quadrant Entry during Laparoscopic Surgery in Obese Patients with a History of Prior Abdominal Surgery
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Abstracts / Journal of Minimally Invasive Gynecology 21 (2014) S136–S190
Table 2 Injury Demographics
Age N Mean Standard Deviation Median Range Body Mass Index N Mean Standard Deviation Median Range Estimated Blood Loss N Mean Standard Deviation Median Range Surgery Time (hours) N Mean Standard Deviation Median Range
No Injury
Injury
321 40.1 7.6 41 9.1 - 54.0
4 29.3 8.9 29.4 18.4 - 40.0
802 33.2 9.8 31.4 13.9 -70.8
7 32.6 7.6 31.8 19.4 - 43.2
795 104.9 143.9 50 0 - 1800
7 50 20.4 50 25 -75
546 3.6 1.4 3.3 1.2 - 8.2
5 4.3 1.4 4.6 2.2 - 5.7
were no long term sequelae from the positioning-related injuries; one patient, however, required physical therapy. The only statistically significant risk factor for positioning-related injury was prior abdominal surgery (p = 0.05). No differences were found in positioning-related injury for increased operative time (P = 0.232), body mass index (P=0.847), age (p = 0.152), smoking history (P = 0.161), or medical comorbidities (P = 0.229 – 0.999). Conclusion: The incidence of positioning related injury among women undergoing robotic surgery was extremely low (0.8%). Due to the low incidence we were unable to identify risk factors for positioning-related injury. A regimented, thorough positioning technique performed by an experienced, dedicated staff can significantly decrease positioning-related injuries in robotic gynecologic surgery. 575 Survey of Cystoscopy Performance at the Time of Hysterectomy Vaynberg D, Jaspan D, Goldberg J. Ob/Gyn, Einstein Medical Center Philadelphia, Philadelphia, Pennsylvania Study Objective: To determine 3rd and 4th year OB/GYN residents’ current experience with and opinion towards cystoscopy at the time of hysterectomy. Design: A 9 part questionnaire survey was designed to assess the utilization of cystoscopy at the time of hysterectomy. Respondents were queried regarding their familiarity with literature regarding selective vs. universal cystoscopy, the number of cystoscopies that they have done, how often cystoscopy has been performed for the different specific types of hysterectomies that they have participated in, and their plans regarding the performance of selective vs. universal cystoscopy for specific types of hysterectomy after they complete their training. Setting: An on-line survey was sent to 3rd and 4th year OB/GYN residents in accredited US programs. Patients: 3rd and 4th year OB/GYN residents. Intervention: An on-line survey, created on www.surveymonkey.com, was sent to 3rd and 4th year OB/GYN residents in accredited US programs. Measurements and Main Results: 56 3rd and 4th year OB/GYN residents completed the survey. 59% reported familiarity with literature regarding
P Value
Odds Ratio
95% CI
0.152
—
—
0.847
—
—
0.151
—
—
0.232
—
—
selective vs. universal cystoscopy. 79% had been involved with a hysterectomy having a bladder or ureter injury. The average number of cystoscopies performed was 44. Residents reported that cystoscopy was performed in > 90% of the following types of hysterectomy: vaginal hysterectomy (VH) 12%; laparoscopically assisted vaginal hysterectomy (LAVH) 14%; supracervial hysterectomy (SCH) 0%; total abdominal hysterectomy (TAH) 2%; laparoscopically assisted supracervical hysterectomy (LASH) 7%; total laparoscopic hysterectomy (TLH) 29%; and including removal of adnexa 5%. Post-residency, universal cystoscopy was planned during 34% of VH, 34% of LAVH, 13% of SCH, 16% of TAH, 21% of LASH, 48% of TLH, and 14% of hysterectomies with removal of adnexa. Conclusion: Universal cystoscopy was performed \ 30% for all types of hysterectomy. Residents plan to perform universal cystoscopy more frequently than occurred in their training. 576 Safety of Left Upper Quadrant Entry during Laparoscopic Surgery in Obese Patients with a History of Prior Abdominal Surgery Wishall KM, Seufert JM, Danis RB, Pereira N, Della Badia CR. Obstetrics and Gynecology, Drexel University College of Medicine/Hahnemann University Hospital, Philadelphia, Pennsylvania Study Objective: To compare the safety of left upper quadrant entry in laparoscopic gynecologic surgery in obese versus non-obese patients with a history of prior abdominal surgery. Design: Retrospective cohort study. Setting: University-affiliated hospital. Patients: We included all patients >18 years of age undergoing laparoscopic gynecologic surgery for benign indications between January 2011 and January 2013. All patients had at least one prior abdominal surgery. Intervention: Left upper quadrant entry. Measurements and Main Results: A total of 82 patients underwent surgery during the study period. The same primary attending surgeon performed all surgeries. Rotating gynecology residents served as assistants during each surgery. Obese patients were defined as those with
Abstracts / Journal of Minimally Invasive Gynecology 21 (2014) S136–S190 2
a body mass index (BMI)>30 kg/m . Thirty-six (43.9%) patients were obese and 46 (56.1%) patients were non-obese. Overall, there were no differences in mean age or parity. There was also no difference in the mean number of previous abdominal surgeries between the two groups. The most common previous surgery was a cesarean delivery, which 29 (80.6%) obese and 27 (58.7%) non-obese patients underwent. Nine (25%) obese and 16 (34.8%) non-obese patients had a previous laparotomy for other indications. Thirteen (36.1%) obese and 18 (39.1%) non-obese patients had a previous laparoscopy. Intra-abdominal adhesions were noted in 15 (32.6%) obese and 16 (44.4%) non-obese patients. There was no difference in the location of adhesions between the two groups (P=0.56). There were no entry-related complications in either study group. Table 1 summarizes our findings.
Parameter
BMI>30 (n=36)
BMI\=30 (n=46)
P
Age (years) Parity Total Abdominal Surgeries Cesarean Delivery Laparotomy Laparoscopy Adhesions Present Location of Adhesions Anterior Abdominal Wall Other Entry-related complications
42.1 (8.1) 1.5 (1.2) – 29 (80.6) 9 (25) 13 (36.1) 16 (44.4) – 7 (19.4) 9 (25) 0 (0)
41.2 (8.2) 1.37 (.95) – 27 (58.7) 16 (34.8) 18 (39.1) 15 (32.6) – 6 (13) 9 (19.6) 0 (0)
.62* .63* .38** – – – .19** .56** – – –
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578 Single-Port Laparoscopic Debulking Surgery of Variant Diffuse Peritoneal Leiomyomatosis with Retroperitoneal Leiomyomatosis: First Report Yoon JH,1 Lee SW,1 Lee SJ,1 Yoo SH,2 Song MJ.3 1Obstetrics and Gynecology, The Catholic University of Medicine of Korea, Suwon-si, Gyeonggi-do, Korea; 2Anesthesiology and Pain Medicine, The Soonchunhyang University of Medicine of Korea, Chunan-si, Chungcheongnam-do, Korea; 3Obstetrics and Gynecology, The Catholic University of Medicine of Korea, Daejeon-si, Chungcheongnam-do, Korea Study Objective: Diffuse peritoneal leiomyomatosis (DPL) is a rare disease with multiple smooth muscle cell proliferation in abdominal and pelvic cavity. DPL is mainly discovered in reproductive age of women and it is associated with high levels of exogenous and endogenous female gonadal steroids and of DPL is low. The retroperitoneal leiomyomatosis (RPL) is also very rare. There is no report of variant DPL with RPL until now.We firstly report a 39-year-old woman with variant DPL with RPL who underwent SPL debulking surgery. Patients: A 39-year-old woman (gravida-1, para-1) presented to the Emergency Department with severe abdominal pain. She had a history of cesarean section 15 years ago and total hysterectomy due to 15-cm diameter uterine leiomyoma 4 years ago. Physical examination revealed distended abdomen and palpable hard mass. Abdominopelvic 3-dimensional computed tomography revealed conglomerated multiple masses scattered in pelvis and abdomen [Figure 1].
Data are presented as mean standard deviation and n (%).* Student’s t-test**Fisher’s exact test.
Conclusion: Left upper quadrant entry is a safe option in obese patients undergoing laparoscopic gynecologic surgery. In addition to its safety profile, our study indicates no failures associated with abdominal entry through the left upper quadrant. Despite these potential benefits, left upper quadrant entry is underutilized in gynecologic surgery.
577 Natural Orifice Transvaginal Endoscopic Surgery (NOTES) for Ovarian Mature Cystic Teratoma Wu K-Y, Lee C-L, Huang C-Y, Han C-M, Yen C-F. Obstetrics and Gynecology, Chang Gung Memorial Hospital at Linko, Tao-Yuan, Taiwan Study Objective: To describe NOTES cysterectomy for ovarian mature cystic teratoma. Design: Retrospective chart review. Setting: The division of endoscopy, department of gynecology in a tertiary referral medical cencer. Patients: Patients with ovarian mature cystic teratoma diagnosed by transvaginal ultrasonography. Intervention: NOTES cystectomy. Measurements and Main Results: From August 2010 to March 2014, 25 consecutive patients underwent NOTES cystectomy for ovarian mature cystic teratoma. The mean (SD; 95% CI)age was 34.8 (9.7; 27.9-41.8) years, and body mass index was 21.6 (2.8; 19.4-23.8). The mean operative time was 45 minutes. THe mean of intra-operative blood loss was 15 ml without blood transfusion. No intra- or post- op complications were noted. NOTES cystectomy were performed successfully in all patients without conversion to traditional laparoscopy or laparotomy. Conclusion: Our preliminary results showed that NOTES cystectomy for ovarian mature cystic teratoma is feasible and safe. However, the procedure cannot be used in patients with cul-de-sac disease, and could have limited use in treating lesions located anterior to the uterus.
Ultrasonography-guided biopsy of omental mass lesion showed benign spindle cell proliferation with smooth muscle differentiation. The patient was transferred to Obstetrics and Gynecology Department. We decided to
Abstracts / Journal of Minimally Invasive Gynecology 21 (2014) S136–S190
Table 2 Injury Demographics
Age N Mean Standard Deviation Median Range Body Mass Index N Mean Standard Deviation Median Range Estimated Blood Loss N Mean Standard Deviation Median Range Surgery Time (hours) N Mean Standard Deviation Median Range
No Injury
Injury
321 40.1 7.6 41 9.1 - 54.0
4 29.3 8.9 29.4 18.4 - 40.0
802 33.2 9.8 31.4 13.9 -70.8
7 32.6 7.6 31.8 19.4 - 43.2
795 104.9 143.9 50 0 - 1800
7 50 20.4 50 25 -75
546 3.6 1.4 3.3 1.2 - 8.2
5 4.3 1.4 4.6 2.2 - 5.7
were no long term sequelae from the positioning-related injuries; one patient, however, required physical therapy. The only statistically significant risk factor for positioning-related injury was prior abdominal surgery (p = 0.05). No differences were found in positioning-related injury for increased operative time (P = 0.232), body mass index (P=0.847), age (p = 0.152), smoking history (P = 0.161), or medical comorbidities (P = 0.229 – 0.999). Conclusion: The incidence of positioning related injury among women undergoing robotic surgery was extremely low (0.8%). Due to the low incidence we were unable to identify risk factors for positioning-related injury. A regimented, thorough positioning technique performed by an experienced, dedicated staff can significantly decrease positioning-related injuries in robotic gynecologic surgery. 575 Survey of Cystoscopy Performance at the Time of Hysterectomy Vaynberg D, Jaspan D, Goldberg J. Ob/Gyn, Einstein Medical Center Philadelphia, Philadelphia, Pennsylvania Study Objective: To determine 3rd and 4th year OB/GYN residents’ current experience with and opinion towards cystoscopy at the time of hysterectomy. Design: A 9 part questionnaire survey was designed to assess the utilization of cystoscopy at the time of hysterectomy. Respondents were queried regarding their familiarity with literature regarding selective vs. universal cystoscopy, the number of cystoscopies that they have done, how often cystoscopy has been performed for the different specific types of hysterectomies that they have participated in, and their plans regarding the performance of selective vs. universal cystoscopy for specific types of hysterectomy after they complete their training. Setting: An on-line survey was sent to 3rd and 4th year OB/GYN residents in accredited US programs. Patients: 3rd and 4th year OB/GYN residents. Intervention: An on-line survey, created on www.surveymonkey.com, was sent to 3rd and 4th year OB/GYN residents in accredited US programs. Measurements and Main Results: 56 3rd and 4th year OB/GYN residents completed the survey. 59% reported familiarity with literature regarding
P Value
Odds Ratio
95% CI
0.152
—
—
0.847
—
—
0.151
—
—
0.232
—
—
selective vs. universal cystoscopy. 79% had been involved with a hysterectomy having a bladder or ureter injury. The average number of cystoscopies performed was 44. Residents reported that cystoscopy was performed in > 90% of the following types of hysterectomy: vaginal hysterectomy (VH) 12%; laparoscopically assisted vaginal hysterectomy (LAVH) 14%; supracervial hysterectomy (SCH) 0%; total abdominal hysterectomy (TAH) 2%; laparoscopically assisted supracervical hysterectomy (LASH) 7%; total laparoscopic hysterectomy (TLH) 29%; and including removal of adnexa 5%. Post-residency, universal cystoscopy was planned during 34% of VH, 34% of LAVH, 13% of SCH, 16% of TAH, 21% of LASH, 48% of TLH, and 14% of hysterectomies with removal of adnexa. Conclusion: Universal cystoscopy was performed \ 30% for all types of hysterectomy. Residents plan to perform universal cystoscopy more frequently than occurred in their training. 576 Safety of Left Upper Quadrant Entry during Laparoscopic Surgery in Obese Patients with a History of Prior Abdominal Surgery Wishall KM, Seufert JM, Danis RB, Pereira N, Della Badia CR. Obstetrics and Gynecology, Drexel University College of Medicine/Hahnemann University Hospital, Philadelphia, Pennsylvania Study Objective: To compare the safety of left upper quadrant entry in laparoscopic gynecologic surgery in obese versus non-obese patients with a history of prior abdominal surgery. Design: Retrospective cohort study. Setting: University-affiliated hospital. Patients: We included all patients >18 years of age undergoing laparoscopic gynecologic surgery for benign indications between January 2011 and January 2013. All patients had at least one prior abdominal surgery. Intervention: Left upper quadrant entry. Measurements and Main Results: A total of 82 patients underwent surgery during the study period. The same primary attending surgeon performed all surgeries. Rotating gynecology residents served as assistants during each surgery. Obese patients were defined as those with
Abstracts / Journal of Minimally Invasive Gynecology 21 (2014) S136–S190 2
a body mass index (BMI)>30 kg/m . Thirty-six (43.9%) patients were obese and 46 (56.1%) patients were non-obese. Overall, there were no differences in mean age or parity. There was also no difference in the mean number of previous abdominal surgeries between the two groups. The most common previous surgery was a cesarean delivery, which 29 (80.6%) obese and 27 (58.7%) non-obese patients underwent. Nine (25%) obese and 16 (34.8%) non-obese patients had a previous laparotomy for other indications. Thirteen (36.1%) obese and 18 (39.1%) non-obese patients had a previous laparoscopy. Intra-abdominal adhesions were noted in 15 (32.6%) obese and 16 (44.4%) non-obese patients. There was no difference in the location of adhesions between the two groups (P=0.56). There were no entry-related complications in either study group. Table 1 summarizes our findings.
Parameter
BMI>30 (n=36)
BMI\=30 (n=46)
P
Age (years) Parity Total Abdominal Surgeries Cesarean Delivery Laparotomy Laparoscopy Adhesions Present Location of Adhesions Anterior Abdominal Wall Other Entry-related complications
42.1 (8.1) 1.5 (1.2) – 29 (80.6) 9 (25) 13 (36.1) 16 (44.4) – 7 (19.4) 9 (25) 0 (0)
41.2 (8.2) 1.37 (.95) – 27 (58.7) 16 (34.8) 18 (39.1) 15 (32.6) – 6 (13) 9 (19.6) 0 (0)
.62* .63* .38** – – – .19** .56** – – –
S181
578 Single-Port Laparoscopic Debulking Surgery of Variant Diffuse Peritoneal Leiomyomatosis with Retroperitoneal Leiomyomatosis: First Report Yoon JH,1 Lee SW,1 Lee SJ,1 Yoo SH,2 Song MJ.3 1Obstetrics and Gynecology, The Catholic University of Medicine of Korea, Suwon-si, Gyeonggi-do, Korea; 2Anesthesiology and Pain Medicine, The Soonchunhyang University of Medicine of Korea, Chunan-si, Chungcheongnam-do, Korea; 3Obstetrics and Gynecology, The Catholic University of Medicine of Korea, Daejeon-si, Chungcheongnam-do, Korea Study Objective: Diffuse peritoneal leiomyomatosis (DPL) is a rare disease with multiple smooth muscle cell proliferation in abdominal and pelvic cavity. DPL is mainly discovered in reproductive age of women and it is associated with high levels of exogenous and endogenous female gonadal steroids and of DPL is low. The retroperitoneal leiomyomatosis (RPL) is also very rare. There is no report of variant DPL with RPL until now.We firstly report a 39-year-old woman with variant DPL with RPL who underwent SPL debulking surgery. Patients: A 39-year-old woman (gravida-1, para-1) presented to the Emergency Department with severe abdominal pain. She had a history of cesarean section 15 years ago and total hysterectomy due to 15-cm diameter uterine leiomyoma 4 years ago. Physical examination revealed distended abdomen and palpable hard mass. Abdominopelvic 3-dimensional computed tomography revealed conglomerated multiple masses scattered in pelvis and abdomen [Figure 1].
Data are presented as mean standard deviation and n (%).* Student’s t-test**Fisher’s exact test.
Conclusion: Left upper quadrant entry is a safe option in obese patients undergoing laparoscopic gynecologic surgery. In addition to its safety profile, our study indicates no failures associated with abdominal entry through the left upper quadrant. Despite these potential benefits, left upper quadrant entry is underutilized in gynecologic surgery.
577 Natural Orifice Transvaginal Endoscopic Surgery (NOTES) for Ovarian Mature Cystic Teratoma Wu K-Y, Lee C-L, Huang C-Y, Han C-M, Yen C-F. Obstetrics and Gynecology, Chang Gung Memorial Hospital at Linko, Tao-Yuan, Taiwan Study Objective: To describe NOTES cysterectomy for ovarian mature cystic teratoma. Design: Retrospective chart review. Setting: The division of endoscopy, department of gynecology in a tertiary referral medical cencer. Patients: Patients with ovarian mature cystic teratoma diagnosed by transvaginal ultrasonography. Intervention: NOTES cystectomy. Measurements and Main Results: From August 2010 to March 2014, 25 consecutive patients underwent NOTES cystectomy for ovarian mature cystic teratoma. The mean (SD; 95% CI)age was 34.8 (9.7; 27.9-41.8) years, and body mass index was 21.6 (2.8; 19.4-23.8). The mean operative time was 45 minutes. THe mean of intra-operative blood loss was 15 ml without blood transfusion. No intra- or post- op complications were noted. NOTES cystectomy were performed successfully in all patients without conversion to traditional laparoscopy or laparotomy. Conclusion: Our preliminary results showed that NOTES cystectomy for ovarian mature cystic teratoma is feasible and safe. However, the procedure cannot be used in patients with cul-de-sac disease, and could have limited use in treating lesions located anterior to the uterus.
Ultrasonography-guided biopsy of omental mass lesion showed benign spindle cell proliferation with smooth muscle differentiation. The patient was transferred to Obstetrics and Gynecology Department. We decided to