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24: Technique for apical suspension at the time of total laparoscopic hysterectomy
Video Cafes
22 Common skin diseases of the vulva: Red down there N. Fang1, T. Muffly1, M. D. Miller2 1 Department of Obstetrics and Gynecology, Denver Health and Hospital Authority, Denver, CO, 2Dermatology, University of Colorado, Aurora, CO
OBJECTIVE: The purpose of this Video Presentation is to review
normal vulvar anatomy as well as the diagnosis and management of benign vulvar skin conditions. Lastly, we will consider the co-morbidities associated with each dermatosis. DESCRIPTION: The ACOG practice bulletin regarding diagnosis and management of vulvar skin disorders from May 2008 lacks photographs or illustrations to help learners understand vulvar dermatoses. We give examples of vulvar papillae, Fox-Fordyce spots, vulvar lentigo, and other normal variants of vulvar anatomy. Vulvar lichen simplex chronicus is a chronic eczematous disease characterized by scaling and lichenified plaque with intense and unrelenting itching, which may result in sleep disruption. Lichen sclerosis is one of the most common papulosquamous diseases that the gynecologist will see. White, shiny, “cigarette paper” thinned wrinkly epithelium on the inside of the labia majora characterizes lichen sclerosus. Vulvar lichen planus symptoms include itching and burning. Lichen planus patients often have vaginal involvement and vaginal scarring is present. CONCLUSION: Vulvar skin conditions are common and it is important to diagnose accurately each condition for proper treatment and prevention. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS: Nancy Fang: Nothing to disclose; Tyler Muffly: Nothing to disclose; Misha D. Miller: Nothing to disclose.
23 Laparoscopic paravaginal defect repair using delayed absorbable barbed suture D. Bastawros, K. Stepp Female Pelvic Medicine and Reconstructive Surgery, Carolinas Health Care System, Charlotte, NC
OBJECTIVE: The purpose of this tip or trick video is to showcase an
alternative method to paravaginal repair using delayed absorbable barbed suture. DESCRIPTION: This tip or trick video illustrates a laparoscopic paravaginal repair from start to finish, showcasing how delayed absorbable barbed suture is used to repair the defect, with audio commentary on benefits and how to identify appropriate tensioning. CONCLUSION: Paravaginal repair has been historically done using permanent suture. Delayed absorbable barbed suture offers a sturdy alternative that is easy to tension, providing even tension, and is without knots. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS: Dina Bastawros: Nothing to disclose; Kevin Stepp: Nothing to disclose.
24 Technique for apical suspension at the time of total laparoscopic hysterectomy A. A. Adajar1, L. Juarez3, J. Nitti2, A. Padilla1 1 Obstetrics and Gynecology, Illinois Institute of Gynecology & Advanced Pelvic Surgery, Chicago, IL, 2Obstetrics & Gynecology, Rush University Medical Center, Chicago, IL, 3Obstetrics & Gynecology, Presence Saint Joseph Hospital of Chicago, Chicago, IL
ajog.org
OBJECTIVE: To demonstrate a laparoscopic vaginal closure technique, performed at the time of benign laparoscopic hysterectomy, for prevention of apical prolapse. Indications for uterosacral ligament suspension, approaches for uterosacral ligament suspension, and advantages of laparoscopic uterosacral ligament suspension will also be discussed. DESCRIPTION: Uterosacral ligament suspension can be used for all degrees of vaginal vault prolapse. This procedure can be tailored depending on the extent of vaginal vault prolapse and coexistence of anterior and/or posterior vaginal wall defects. The goal of uterosacral ligament suspension is to create a well-supported vagina with adequate length. Uterosacral ligament suspension may be performed from an abdominal, vaginal or laparoscopic approach. The vaginal approach has been noted for a reported incidence of ureteral compromise in 4.2 to 11% of cases where as the laparoscopic approach has not been noted to have ureteral compromise. Most of these incidents may only require a suture release but some may require setting or re-implantation of the ureter. The laparoscopic approach allows for direct visualization of the ureters, and allows for access to the paravaginal space. Other advantages with the use of laparoscopy includes decreased estimated blood loss, decreased length of hospital stay, and has been found to have superior apical support and total vaginal length. CONCLUSION: Apical suspension performed at the time of benign hysterectomy is recommended to decrease the risk of pelvic organ prolapse. Uterosacral ligament suspension, when performed from a laparoscopic approach, has less risks of complications compared to a vaginal approach. The following video demonstrates a laparoscopic technique to incorporate the uterosacral ligaments for (native Level 1) apical support, when closing the vaginal cuff. This approach has clear benefits when performing a benign hysterectomy.
DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS: Allan A. Adajar: Teleflex Inc., speaker, honorarium; Stryker Endoscopy, consultant, honorarium; Transenterix, consultant, honorarium; Lourdes Juarez: Nothing to disclose; James Nitti: Nothing to disclose; Andrea Padilla: Nothing to disclose.
25 Robotic assisted laparoscopic cerclage placement during pregnancy J. R. Kanter, J. R. Lue Obstetrics and Gynecology, Augusta University, Augusta, GA
OBJECTIVE: Robotic assisted laparoscopic cerclage is a safe and
effective approach in the patient who is not a good candidate for a vaginal cerclage. Cervical insufficiency complicates approximately 1% of all pregnancies. Abdominal cerclage is currently indicated for patients with history of cervical insufficiency and prior failed vaginal cerclage, however, it carries significantly more morbidity when performed via the traditional open abdominal approach. Through this video, surgical technique for successful placement of a minimally invasive robotic assisted laparoscopic cerclage is outlined and demonstrated. DESCRIPTION: A 37-year-old, gravida 4 para 0 presented at 10 weeks’ gestational age with a history of cervical insufficiency, prior second trimester pregnancy losses after vaginal cerclages, and cervical length of 1.5 cm with funneling. Decision was made to place a robotic
S626 American Journal of Obstetrics & Gynecology Supplement to MARCH 2017
22 Common skin diseases of the vulva: Red down there N. Fang1, T. Muffly1, M. D. Miller2 1 Department of Obstetrics and Gynecology, Denver Health and Hospital Authority, Denver, CO, 2Dermatology, University of Colorado, Aurora, CO
OBJECTIVE: The purpose of this Video Presentation is to review
normal vulvar anatomy as well as the diagnosis and management of benign vulvar skin conditions. Lastly, we will consider the co-morbidities associated with each dermatosis. DESCRIPTION: The ACOG practice bulletin regarding diagnosis and management of vulvar skin disorders from May 2008 lacks photographs or illustrations to help learners understand vulvar dermatoses. We give examples of vulvar papillae, Fox-Fordyce spots, vulvar lentigo, and other normal variants of vulvar anatomy. Vulvar lichen simplex chronicus is a chronic eczematous disease characterized by scaling and lichenified plaque with intense and unrelenting itching, which may result in sleep disruption. Lichen sclerosis is one of the most common papulosquamous diseases that the gynecologist will see. White, shiny, “cigarette paper” thinned wrinkly epithelium on the inside of the labia majora characterizes lichen sclerosus. Vulvar lichen planus symptoms include itching and burning. Lichen planus patients often have vaginal involvement and vaginal scarring is present. CONCLUSION: Vulvar skin conditions are common and it is important to diagnose accurately each condition for proper treatment and prevention. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS: Nancy Fang: Nothing to disclose; Tyler Muffly: Nothing to disclose; Misha D. Miller: Nothing to disclose.
23 Laparoscopic paravaginal defect repair using delayed absorbable barbed suture D. Bastawros, K. Stepp Female Pelvic Medicine and Reconstructive Surgery, Carolinas Health Care System, Charlotte, NC
OBJECTIVE: The purpose of this tip or trick video is to showcase an
alternative method to paravaginal repair using delayed absorbable barbed suture. DESCRIPTION: This tip or trick video illustrates a laparoscopic paravaginal repair from start to finish, showcasing how delayed absorbable barbed suture is used to repair the defect, with audio commentary on benefits and how to identify appropriate tensioning. CONCLUSION: Paravaginal repair has been historically done using permanent suture. Delayed absorbable barbed suture offers a sturdy alternative that is easy to tension, providing even tension, and is without knots. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS: Dina Bastawros: Nothing to disclose; Kevin Stepp: Nothing to disclose.
24 Technique for apical suspension at the time of total laparoscopic hysterectomy A. A. Adajar1, L. Juarez3, J. Nitti2, A. Padilla1 1 Obstetrics and Gynecology, Illinois Institute of Gynecology & Advanced Pelvic Surgery, Chicago, IL, 2Obstetrics & Gynecology, Rush University Medical Center, Chicago, IL, 3Obstetrics & Gynecology, Presence Saint Joseph Hospital of Chicago, Chicago, IL
ajog.org
OBJECTIVE: To demonstrate a laparoscopic vaginal closure technique, performed at the time of benign laparoscopic hysterectomy, for prevention of apical prolapse. Indications for uterosacral ligament suspension, approaches for uterosacral ligament suspension, and advantages of laparoscopic uterosacral ligament suspension will also be discussed. DESCRIPTION: Uterosacral ligament suspension can be used for all degrees of vaginal vault prolapse. This procedure can be tailored depending on the extent of vaginal vault prolapse and coexistence of anterior and/or posterior vaginal wall defects. The goal of uterosacral ligament suspension is to create a well-supported vagina with adequate length. Uterosacral ligament suspension may be performed from an abdominal, vaginal or laparoscopic approach. The vaginal approach has been noted for a reported incidence of ureteral compromise in 4.2 to 11% of cases where as the laparoscopic approach has not been noted to have ureteral compromise. Most of these incidents may only require a suture release but some may require setting or re-implantation of the ureter. The laparoscopic approach allows for direct visualization of the ureters, and allows for access to the paravaginal space. Other advantages with the use of laparoscopy includes decreased estimated blood loss, decreased length of hospital stay, and has been found to have superior apical support and total vaginal length. CONCLUSION: Apical suspension performed at the time of benign hysterectomy is recommended to decrease the risk of pelvic organ prolapse. Uterosacral ligament suspension, when performed from a laparoscopic approach, has less risks of complications compared to a vaginal approach. The following video demonstrates a laparoscopic technique to incorporate the uterosacral ligaments for (native Level 1) apical support, when closing the vaginal cuff. This approach has clear benefits when performing a benign hysterectomy.
DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS: Allan A. Adajar: Teleflex Inc., speaker, honorarium; Stryker Endoscopy, consultant, honorarium; Transenterix, consultant, honorarium; Lourdes Juarez: Nothing to disclose; James Nitti: Nothing to disclose; Andrea Padilla: Nothing to disclose.
25 Robotic assisted laparoscopic cerclage placement during pregnancy J. R. Kanter, J. R. Lue Obstetrics and Gynecology, Augusta University, Augusta, GA
OBJECTIVE: Robotic assisted laparoscopic cerclage is a safe and
effective approach in the patient who is not a good candidate for a vaginal cerclage. Cervical insufficiency complicates approximately 1% of all pregnancies. Abdominal cerclage is currently indicated for patients with history of cervical insufficiency and prior failed vaginal cerclage, however, it carries significantly more morbidity when performed via the traditional open abdominal approach. Through this video, surgical technique for successful placement of a minimally invasive robotic assisted laparoscopic cerclage is outlined and demonstrated. DESCRIPTION: A 37-year-old, gravida 4 para 0 presented at 10 weeks’ gestational age with a history of cervical insufficiency, prior second trimester pregnancy losses after vaginal cerclages, and cervical length of 1.5 cm with funneling. Decision was made to place a robotic
S626 American Journal of Obstetrics & Gynecology Supplement to MARCH 2017