1235 Myometrial Cells in Pelvic Washings at time of Benign Hysterectomy

Abstracts / Journal of Minimally Invasive Gynecology 26 (2019) S98−S231

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Design: A multi-center retrospective cohort study was conducted, consisting of a retrospective chart review and a self-administered study questionnaire on reproductive outcomes. Setting: Sunnybrook Health Sciences Center and St. Michael’s Hospital, two tertiary care centers affiliated with the University of Toronto. Patients or Participants: Women of childbearing age (18-45 years old) who underwent AM between June 2002 and 2012 were consecutively sampled. 1099 patients met inclusion criteria and 144 returned the study questionnaire. After excluding patients who did not attempt to conceive post-operatively, 82 patients were included in the final statistical analysis. Interventions: Use of a peri-cervical tourniquet during AM. Measurements and Main Results: Unadjusted and multivariable regression analysis was used to compare the groups of patients. Mean age of patients at time of surgery was 36 years. 28% of surgeries involved use of peri-cervical tourniquet. There was no significant association between the use of tourniquet and live birth rate (p=0.35). Similarly, there was no significant difference between the use of tourniquet and length of time attempting conception after surgery (p=0.91). Data analysis is ongoing and further results will be presented. Conclusion: Our study suggests no significant association between use of tourniquet and live birth outcomes. Concerns about the tourniquet’s impact on fertility may therefore be unfounded, and a more widespread uptake of peri-cervical tourniquet during AM may contribute to limiting surgical blood loss. Further prospective research is warranted with a larger sample size.

subsequent blood transfusion, which is an important morbidity associated with this elective procedure in reproductive-aged women. Gynecologic surgeons have utilized a number of interventions in an attempt to reduce rates of surgical bleeding during myomectomy but clinical practice varies considerably. This video demonstrates various evidence-based strategies aimed at minimizing surgical bleeding during myomectomy. Setting: N/A Interventions: Techniques covered in this video include: (1) Preoperative use of medications such as vaginal/rectal misoprostal and intravenous tranexamic acid, (2) Intramyometrial injection of dilute vasopressin and (3) Temporary uterine artery occlusion with pericervical tourniquet. Conclusion: Intraoperative blood loss is a significant surgical risk during laparoscopic, robotic and abdominal myomectomy and perioperative transfusion rates are high. There are significant short-term and long-term risks associated with blood transfusion and gynecologic surgeons must employ evidence-based interventions in order to minimize blood loss and decrease the need for blood transfusions.

Virtual Poster Session 1: Laparoscopy (10:10 AM — 10:20 AM) 10:10 AM: STATION K 1306 Robotic Myomectomy Beardsley R,* Elkattah RA. Obstetrics and Gynecology, University of Illinois College of Medicine Peoria, Peoria, IL *Corresponding author. Video Objective: Describing a minimally invasive technique for a solitary intramural myomectomy. Setting: A 28-year-old African American nulliparous woman presented with pelvic pressure and ultrasound evidence of a large posterior/fundal intramural fibroid measuring 6 cm. She had abnormal and heavy uterine bleeding that was refractory to medical therapy. Definitive surgical treatment was desired and thus a robotic approach was planned. Interventions: Myomectomy of a solitary intramural uterine fibroid is performed robotically. Several surgical tips are utilized and described herein. Tip#1: horizontal incision; Tip#2: Utility of a tenaculum for traction; Tip#3: Electrosurgical coagulative dissection; Tip#4: Layered closure with a resorbable barbed suture. Conclusion: Hemostatic horizontal incisions, traction with a tenaculum, coagulative dissection, and the utility of a barbed resorbable suture are all steps one can utilize for successful completion of a myomectomy via robotic route. Virtual Poster Session 1: Laparoscopy (10:10 AM — 10:20 AM) 10:10 AM: STATION L 1189 Intraoperative Strategies to Minimize Blood Loss During Myomectomy Nensi A,* Robertson D. Obstetrics and Gynecology, St. Michael’s Hospital, Toronto, ON, Canada *Corresponding author. Video Objective: Fibroids are common, benign masses which can result in significant morbidity for affected women due to heavy menstrual bleeding and anemia, bulk symptoms and infertility. In women who are pre-menopausal or wishing to retain future fertility, the surgical management of symptomatic fibroids is by way of myomectomy. The surgical removal of fibroids can be associated with significant intraoperative blood loss and

Virtual Poster Session 1: Laparoscopy (10:10 AM — 10:20 AM) 10:10 AM: STATION M 1751 Understanding the Anatomy of Anterior Parametrium a Key Step for Prevention of Pelvic Recurrences Following Laparoscopic Radical Hysterectomy Pattanaik S,* Jathar AH, Puntambekar SP, Goel A. Galaxy CARE Laparoscopy Institute Pvt. Ltd, PUNE, India *Corresponding author. Video Objective: This video is a demonstration of the concept of parametrium and its significance in radical hysterectomy for early stage cervical cancer. Setting: It includes a series of three cases, one classical & two nerve sparing radical hysterectomies showing complete parametrectomy. The dissection of posterior and lateral parametrium are technically easier in comparison to that of anterior parametrium. Anteriorly and posteriorly, protection to the spread of cervical cancer is provided by the cervico-vaginal fascia and Denonvilliers fascia respectively. Deficiency or the weakest area facilitating tumor spread lies on the lateral aspects and it is incomplete parametrectomy that is the reason for local recurrences. Interventions: Understanding the anatomy of parametrium and paracervix is the key to achieve optimum tumor clearance. “Lymphatics follow the veins”, was the dictum that led to the origin for the need of parametrectomy in this radical procedure. Schematic diagrams depict the various extents of the parametrium in the three-dimensional scenario. The inferior vesical vein is ligated around two centimeters lateral to the lateral border of vagina making it the lateral extent on either side enforcing complete parametrial clearance. Meticulous dissection of the ureter with predictive anatomy, achieving hemostasis and preserving the innervation in type C1 hysterectomies were the various challenges encountered during the procedure! But all you need is a crystal-clear picture of the anatomy and laparoscopic approach is an added advantage due to a magnified vision. Conclusion: Thus, this video makes an effort to popularize the concept of anterior parametrectomy. The negligence due to ignorance of the anatomy or incompetence to achieve it leads to higher rates of recurrences and lower survival rates in minimally invasive approach for cervical cancer as highlighted in the LACC trial. Virtual Poster Session 1: Laparoscopy (10:10 AM — 10:20 AM) 10:10 AM: STATION N 1235 Myometrial Cells in Pelvic Washings at time of Benign Hysterectomy

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Abstracts / Journal of Minimally Invasive Gynecology 26 (2019) S98−S231

Chen J,1,* Wield A,2 Savilo E,3 Mahnert N,4 Siedhoff MT,2 Wright KN2. 1 Minimally Invasive Gynecology, Banner University Medical Center Phoenix, Phoenix, AZ; 2Department of Gynecologic Surgery, Cedars Sinai Medical Center, Los Angeles, CA; 3Pathology, Banner University Medical Center Phoenix, Phoenix, AZ; 4Minimally Invasive Gynecologic Surgery, University of Arizona College of Medicine - Phoenix, Phoenix, AZ *Corresponding author.

operated on by a general surgeon, at same time of gynecologic surgery (1) or at a later date (2). No significant sequelae occurred. Conclusion: The appendix should be evaluated during gynecologic laparoscopy, as incidental findings may be identified including malignancies. It is safe for trained gynecologists to perform a laparoscopic appendectomy, but a general surgeon should be consulted intra-operatively when a suspicious mass or malignancy is noted. Future research could evaluate postoperative pain profiles, increased costs and surgical time, and incidence of appendiceal pathology in the endometriosis population.

Study Objective: To evaluate if smooth muscle cells can be detected in pelvic washings at time of intact hysterectomy. Design: A multi-centered pilot cohort study. Setting: Two academically affiliated tertiary referral centers. Patients or Participants: Patients undergoing total hysterectomy for benign indications without morcellation by minimally invasive gynecologic surgeons were enrolled from January 2018 to July 2018. Interventions: Pelvic washings were collected at 2 times during surgery: after abdominal entry and after vaginal cuff closure. Cell blocks were generated, slides were stained using hematoxylin and eosin (H&E), smooth muscle actin (SMA) and desmin, and interpreted by one expert pathologist at each institution. Measurements and Main Results: Thirty-eight subjects were recruited; three subjects were excluded due to unplanned morcellation. Smooth muscle uterine cells were detected in 1 pre-wash specimen and 2 post-wash cases. The group with positive washings was noted to have longer procedure time (136 minutes versus 114 minutes), lower blood loss (25 mL versus 86 mL) and higher uterine weight compared to negative washings group (242 grams versus 234 grams). Conclusion: Tissue dissemination of uterine cells may be possible at time of hysterectomy. Larger prospective studies are needed in order to better describe the incidence of and risk factors for tissue dissemination. Virtual Poster Session 1: Laparoscopy (10:10 AM — 10:20 AM) 10:10 AM: STATION O 2462 Don’t Forget the Appendix! Incidental Appendix Findings During Laparoscopic Pelvic Surgery Hendricks R,1,* Sasaki KJ,1,2 Miller CE1,2. 1OBGYN, Advocate Lutheran General Hospital, Park Ridge, IL; 2The Advanced Gynecologic Surgery Institute, Naperville, IL *Corresponding author. Study Objective: Evaluate the incidence of appendectomy for grossly abnormal appearance during laparoscopic gynecologic surgery for benign indications and pathologic concordance. Design: Retrospective chart review of patients who underwent an appendectomy during laparoscopic gynecologic surgery for other indications. Setting: Surgeries by Advanced Gynecologic Surgery Institute (AGSI), a group of three highly skilled minimally invasive gynecologic surgeons, at three community hospitals in the Chicago area. Patients or Participants: A total of 3,478 patients underwent laparoscopic surgery by AGSI between January 1, 2013 through February 28, 2018. Seventy-three patients underwent appendectomy, and fifty-six were included in final analysis. All patients were 18 years of age or older with available operative and pathology reports. Interventions: IRB approval was obtained and a retrospective chart review conducted using outpatient and inpatient electronic medical records. Measurements and Main Results: Patients were assessed for age, body mass index, surgical indication, procedure performed, intra-operative appendiceal findings, blood loss, pathology, intra-operative events, and postoperative complications. Intraoperatively, the most common indication for appendectomy was endometriosis or fibrosis (61.8%) of which 58.8% had confirmatory pathology and 23.5% had normal pathology. Overall, 75.0% of the specimens were positive for a pathologic process. Four (7.2%) appendiceal malignancies were found, three mucinous and one carcinoid tumor. All three patients with mucinous tumors were

Virtual Poster Session 1: Laparoscopy (10:10 AM — 10:20 AM) 10:10 AM: STATION P 1173 A Surgical Technique for the Laparoscopic Intact Enucleation of an Interstitial Ectopic Pregnancy and Unilateral Selective Devascularization of the Uterus Freeman A*. Evin Women’s Health, Brisbane, QLD, Australia *Corresponding author. Video Objective: To describe a step by step surgical technique for the laparoscopic intact enucleation of an interstitial ectopic pregnancy and unilateral selective devascularization of the uterus. Setting: Interstitial ectopic pregnancy accounts for 2% to 4% of all ectopic pregnancies. Initial inaccurate diagnosis can occur in 40% of cases. The laparoscopic cornual resection or cornuotomy is becoming more commonly used procedure. However, laparoscopic procedure may need to be converted to laparotomy due to bleeding and or adhesions in up to 5.4% of cases. In addition, the incidence of persistent interstitial ectopic pregnancy after laparoscopic cornual resection or cornuotomy can be as high as 7% to 8%. The patient was 44 years old G4P4 (four vaginal deliveries) and had history of vaginal bleeding, seven weeks of amenorrhea and initial ultrasound findings of tubal ectopic pregnancy. She had laparoscopic partial salpingectomy for possible early tubal ectopic pregnancy by another surgical team one week prior. Interventions: With the negative histology of tube, the findings of right interstitial ectopic pregnancy on repeat pelvic ultrasound and an elevated human chorionic gonadotropin (HCG) of 20,520, laparoscopic intact enucleation (similar to myomectomy) of ectopic pregnancy was performed. Techniques used include the intramyometrial injection of diluted vasopressin and unilateral ligation of ascending branches of uterine artery and veins by surgical clips. The operation time was 65 minutes. The estimated blood loss was 30 mL. There was no intra or post-operative complication. Conclusion: Laparoscopic intact enucleation of interstitial ectopic pregnancy is possible. It can be done by only using three 5 mm trocars and intact enucleation may reduce the incidence of persistent ectopic pregnancy. Virtual Poster Session 1: Laparoscopy (10:10 AM — 10:20 AM) 10:10 AM: STATION Q 1997 The Usefulness of Uterine Manipulation Simulation Among Ob-Gyn Residents as Bottom Person Prior to Assisting a Total Laparoscopic Hysterectomy: A Quirino Memorial Medical Center Experience Baltazar MRA,* Aquino-Aquino PV. Obstetrics and Gynecology, Quirino Memorial Medical Center, Quezon City, Philippines *Corresponding author. Study Objective: To determine the usefulness of uterine manipulation in a simulator prior to assisting as bottom person during total laparoscopic hysterectomies (TLH) among OB-GYN residents of Quirino Memorial Medical Center. Design: Single-blinded Randomized Controlled Trial. Setting: Quirino Memorial Medical Center with Residency Training in OB-GYN