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2679 Management of a Large Uterus and its Complications to a Successful Laparoscopic Surgery
Abstracts / Journal of Minimally Invasive Gynecology 26 (2019) S98−S231
S107
she successfully underwent oocyte cryopreservation with eggs aspirated from both ovaries. Conclusion: Hernia uterus inguinale is a rare condition in which uterine tissue and occasionally adnexa herniate through the inguinal ring. It can present as an asymptomatic palpable mass or rarely as pelvic pain. Most reports have focused on its association with persistent M€ullerian duct syndrome, which affects phenotypically male infants. While there are few reports of hernia uterus inguinale occurring in adult females, this case highlights the importance of keeping it in the differential in a patient with an inguinal mass and recognizing the potential for its associated morbidity and the ability to manage it surgically, if needed, through a minimally invasive approach.
Patients or Participants: Eighty-six pregnant women who underwent 86 operations for suspected adnexal pathology at our institute. Laparoscopy was performed during the first trimester in 13 patients, second trimester in 33 patients. The remaining 40 patients underwent laparotomy, 8 during the first trimester, 31 during the second trimester and 1 during third trimester. Interventions: Laparoscopy or laparotomy for the management of adnexal masses during pregnancy from January 1996 to March 2012. Measurements and Main Results: Operative and postoperative maternal complications, miscarriage, congenital malformations, and newborn longterm outcome. Results: The laparoscopy group had a significantly shorter mean operative time (68.5§4.2 vs 49.9§3.4 min, P=0.0008), lower mean blood loss (19.9§2.3 vs 45.3§4.6 ml), shorter mean flatus time after operation (22.0§0.7 vs 43.1§2.1 h) and mean hospital stay (2.8§0.1 vs 6.6§ 0.2 days, P=0.004) than the laparotomy group. All group patients didn’t require a blood transfusion. In multivariate analysis, there was no significant difference between laparoscopy and laparotomy group in obstetric outcomes, including preterm delivery and miscarriage rate, after adjusting for confounding factors, such as gestational age at surgery, emergency surgery and mass size. The median follow-up time was 3.5 years (range, 1.511.5 years). The median age of the child was 2.5 years (range, 1-9.5 years). All babies were healthy. Conclusion: In this retrospective study, the successful outcome suggests that operative laparoscopy for adnexal masses performed during pregnancy is safe and feasible when performed by experienced surgeons. Procedures in the second trimester without emergency indications is preferable.
Virtual Poster Session 1: Laparoscopy (10:00 AM — 10:10 AM) 10:00 AM: STATION K 2924 Oophoropexy in Adolescent Patients Gabra M,* Aguirre AG. University of Arizona, Tucson, AZ *Corresponding author. Video Objective: This video demonstrates a technique of oophoropexy through plication of the utero-ovarian ligament to the round ligament. Setting: The patient is a 13 year old P0 with a history of right ovarian torsion 10 months prior, for which she underwent laparoscopic detorsion without oophoropexy. She re-presented to the ED with two weeks of severe intermittent right lower abdominal pain, associated with nausea and vomiting. MRI abdomen/pelvis revealed twisting of the right ovarian pedicle. In addition, the right ovary was enlarged due to ovarian stromal edema, and there was peripheralization of the follicles. There was no ovarian cyst or mass. At the time of evaluation, the patient was not experiencing pain and she was clinically stable. She was suspected to have intermittent torsion. The patient and her parents were counseled on the option of observation and outpatient follow up versus surgical management with oophoropexy. They desired to proceed with surgical management. Interventions: Oophoropexy was performed with a horizontal mattress of non-absorbable Polyester suture from the round ligament, through the mesosalpinx, and to the utero-ovarian ligament. Conclusion: Evidence supports ovarian oophoropexy rather than oophorectomy for recurrent ovarian torsion in adolescents. Despite this the National Inpatient Sample (NIS) estimates 78% of adolescents underwent oophorectomy. We demonstrate a method of oophoropexy for recurrent ovarian torsion. The case patient has remained asymptomatic since her procedure. In conclusion, oophoropexy should be considered for adolescent patients with recurrent ovarian torsion to decrease risk of recurrence and to preserve fertility. Virtual Poster Session 1: Laparoscopy (10:00 AM — 10:10 AM) 10:00 AM: STATION L 2347 A Comparison of Laparoscopic Versus Laparotomy Management for Adnexal Masses During Pregnancy: A Retrospective Study With 16-Year Experience Li M*. Obstetrics and Gynecology, Affiliated of Beijing ChaoYang Hospital, Capital University of Medical Science, Beijing, China *Corresponding author. Study Objective: To evaluate the surgical, obstetric outcomes between laparoscopic and laparotomy management for adnexal mass during pregnancy. Design: Retrospective comparative study. Setting: University tertiary care referral center for endoscopic surgery.
Virtual Poster Session 1: Laparoscopy (10:00 AM — 10:10 AM) 10:00 AM: STATION M 2679 Management of a Large Uterus and its Complications to a Successful Laparoscopic Surgery Cervantes GV,1,* Ohara F,2 Tomasi MC,3 Ribeiro PA,2 Ribeiro HA2. 1 Laparoscopic Surgery and Endometriosis, Irmandade da Santa Casa de Miseric ordia de S~ ao Paulo, S~ ao Paulo, Brazil; 2Irmandade da Santa Casa de Miseric ordia de S~ ao Paulo, S~ ao Paulo, Brazil; 3Irmandade da Santa Casa de Miseric ordia de S~ ao Paulo, sao paulo, Brazil *Corresponding author. Video Objective: Present and demonstrate a pre operative and surgical management of large uterus and its complications. Setting: A 37-years-old, G2P2, who complained of progressive dysmenorrhea, genital pelvic and low-back pain without improvement with hormonal treatment. Complementary exams showed deep endometriosis on the posterior compartment, myomatosis uterus with 848cc of volume and an 139cc cystic right ovarian mass, which generated an extrinsically compression on the right ureter and ureterohydronephrosis. Interventions: Pre operative management consisted in double J catheter in the right ureter and uterine artery embolization with prophylactic antibiotic 3 months before the surgery. Final complementary exams showed an uterine volume reduction to 313cc. Laparoscopic treatment consisted of inspecting pelvic and abdominal cavities. Right ovarian mass was adhered to the posterior compartment including ovarian fossa, rectovaginal septum and right uterossacral ligament. Strategy consisted of right ovariectomy, Latsko and Okabayashi space dissection to identify bilateral hypogastric nerves and ureters. After identifying anatomy landmarks, endometriotic lesions were removed from uterossacral ligament and ureter. Rectovaginal septum was dissecated and bowel superficial lesion identified. Hysterectomy and bilateral salpingectomy were performed as treatment. Linear stapler was used to remove bowel endometriotic lesion. Ureterohydronephrosis became absent and controlled and Double J catheter was removed right after the surgery. Double J catheter right after surgery. Conclusion: Pre operative strategies are very important to a successful surgery. Double J catheter is a temporary intervention to prevent ureteres
S108
Abstracts / Journal of Minimally Invasive Gynecology 26 (2019) S98−S231
complications. Uterine artery embolization reduced more than 50% of the uterine volume. These strategies facilitated the access to the pelvis and promoted excellent laparoscopic view to completely treat myomatosis and deep endometriosis.
pregnancy. The myometrial lesion showed connection to the endometrial cavity. The site of removal was closed with interrupted polyglactin endosutures. The postoperative course was uneventful and the final pathologic report was an adenomyomatous polyp. Because the myometrial lesion showed connection to the endometrial cavity, hysteroscopic examination was performed after recovery, demonstrated a polypoid mass and a uterine septum. Hysteroscopic polypectomy was performed and the pathological diagnosis was also an adenomyomatous polyp. Conclusion: To our knowledge, this is the first report of an adenomyomatous polyp growing through the myometrial layer, into the pelvic cavity. Further study and a larger number of cases are needed to elucidate the mechanism which lies beneath the penetrating growth pattern of the adenomyomatous polyp into the myometrium.
Virtual Poster Session 1: Laparoscopy (10:00 AM — 10:10 AM) 10:00 AM: STATION N 1450 Laparoscopic Cornual Resection of Heterotopic Cornual Pregnancy Jiang L,* Chan-Tiopaianco M, Horng HC, Chen YJ, Wang PH. Obstetrics and Gynecology, Taipei Veteran General Hospital, Taipei, Taiwan *Corresponding author. Video Objective: Laparoscopic heterotopic cornual pregnancy resection. Setting: A 41 y/o woman, with history of G3P0E1(status post right salpingectomy)SA1 got pregnancy via IVF with frozen embryo transferred. Four embryos were transferred. However, at about gestational age 6 weeks, two intrauterine gestational sac and one right cornual gestational sac were found. All the fetus had heart beats. Thin uterine wall at right cornus about 0.53cm in size was also noticed. To preserve normal intrauterine pregnancy, surgical intervention was suggested, and the patient received laparoscopic cornual resection surgery. Interventions: During operation, to prevent fetus injury, we didn’t use uterine manipulator or pitressin injection. We also avoided electrical energy device to decrease thermal effect to fetus. Because of the rich blood flow of uterus, we hoped to decreased the surgical time, and barbed suture was used. Multiple suture layers for uterus was applied. We also used vaginal ultrasound during operation to check the uterine condition. After checking bleeders, adhesion barrier was used. For postoperative medication, progesterone was prescribed for tocolysis. We checked ultrasound after the surgery, and only one fetus with fetal heart beat was noticed. Conclusion: Laparoscopic heterotypic cornual pregnancy resection is feasible with the advantages of decreased hospital stay, less wound pain, and less use of analgesics. Further obstetrics outcome is reassuring in current studies. Virtual Poster Session 1: Laparoscopy (10:00 AM — 10:10 AM) 10:00 AM: STATION O 1402 Hemoperitoneum Caused by Ectopic Location of an Adenomyomatous Polyp Moon HS,* Koo JS, Nam GI. Obstetrics & Gynecology, Good Moonhwa Hospital, Busan, Korea, Republic of (South) *Corresponding author. Video Objective: To demonstrate an unusual case of hemoperitoneum caused by adenomyomatous polyps growing through the myometrial layer, into the pelvic cavity. Setting: An academic teaching hospital. Interventions: A 46-year-old woman was referred for postcoital abdominal pain for 3 days. Physical examination revealed both direct and rebound tenderness of the whole abdomen. Her vital signs were stable. The hemoglobin level was 12.7g/dL, CA-125 elevated to 80.3 U/ml (reference range, 0-35 U/ml) and serum b-hCG level below 1.2mIU/ml. Transvaginal ultrasound demonstrated free fluid in cul-de-sac. The initial clinical diagnosis was hemoperitoneum and she underwent operative laparoscopy. Approximately 500cc of blood and clots were pooled in the abdomino-pelvic cavity. A brown-colored soft lesion with an irregular surface was noted in the right cornua which was suspected to be a ruptured interstitial pregnancy. Removed tissue specimen was sent for frozen biopsy, of which result was endometrial tissue not related to
Virtual Poster Session 1: Laparoscopy (10:00 AM — 10:10 AM) 10:00 AM: STATION P 1787 A Case of Female Genital Tuberculosis with Superimposed Tubo-Ovarian Abscess in a Developed Nation Fowler ML,* O’Rourke-Suchoff D, Steer J, Noel NL, Hendessi P. Boston Medical Center, Boston, MA *Corresponding author. Video Objective: To describe the surgical techniques in a case of female genital tuberculosis (TB) with superimposed tubo-ovarian abscess (TOA) in a developed country. Setting: A 22-year-old G0 who was born in Vietnam presented to the emergency room with pelvic pain and known bilateral hydrosalpinx. She was treated for pelvic inflammatory disease, and a TB test was sent and later returned as positive. Her initial chest x-ray was read as normal. When she returned for follow up, a CT scan was planned to evaluate the extent of pulmonary and possible pelvic disease. However, before this could be done, she became febrile, requiring hospitalization with concern for TB or TOA. Interventions: Once pulmonary and peritoneal TB were suspected based on imaging, diagnosis of TB was attempted via sputum culture and endometrial biopsy. However, there was significant concern that the patient had a tubo-ovarian abscess given the high fevers, dilated tubes, and delay in urogenital TB diagnosis confirmation. This led to the patient being taken to the operating room for diagnostic laparoscopy and drainage of the tube. This video shows the techniques used to evaluate pelvic organs when acute infection is suspected. Ultimately, the endometrial biopsy returned positive for culture of Mycobacterium tuberculosis, confirming the diagnosis of female genital tuberculosis. Conclusion: This patient was diagnosed genital TB with superimposed bacterial infection, leading to the pyosalpinx. Female genital TB can cause a diagnostic challenge, and surgery may be required to achieve a diagnosis. Pre-operative planning and careful surgical technique is essential when faced with dense adhesions. Virtual Poster Session 1: Laparoscopy (10:00 AM — 10:10 AM) 10:00 AM: STATION Q 2932 Total Laparoscopic Hysterectomy: 5 Step Approach for Uteri Larger than 500 Grams Katebi Kashi P,* Hamilton CA. OB/GYN, Inova FairFax Hospital, Falls Church, VA *Corresponding author. Video Objective: To demonstrate a five step approach facilitating successful completion of Total Laparoscopic Hysterectomy (TLH) in patients with uteri larger than 500 grams.
S107
she successfully underwent oocyte cryopreservation with eggs aspirated from both ovaries. Conclusion: Hernia uterus inguinale is a rare condition in which uterine tissue and occasionally adnexa herniate through the inguinal ring. It can present as an asymptomatic palpable mass or rarely as pelvic pain. Most reports have focused on its association with persistent M€ullerian duct syndrome, which affects phenotypically male infants. While there are few reports of hernia uterus inguinale occurring in adult females, this case highlights the importance of keeping it in the differential in a patient with an inguinal mass and recognizing the potential for its associated morbidity and the ability to manage it surgically, if needed, through a minimally invasive approach.
Patients or Participants: Eighty-six pregnant women who underwent 86 operations for suspected adnexal pathology at our institute. Laparoscopy was performed during the first trimester in 13 patients, second trimester in 33 patients. The remaining 40 patients underwent laparotomy, 8 during the first trimester, 31 during the second trimester and 1 during third trimester. Interventions: Laparoscopy or laparotomy for the management of adnexal masses during pregnancy from January 1996 to March 2012. Measurements and Main Results: Operative and postoperative maternal complications, miscarriage, congenital malformations, and newborn longterm outcome. Results: The laparoscopy group had a significantly shorter mean operative time (68.5§4.2 vs 49.9§3.4 min, P=0.0008), lower mean blood loss (19.9§2.3 vs 45.3§4.6 ml), shorter mean flatus time after operation (22.0§0.7 vs 43.1§2.1 h) and mean hospital stay (2.8§0.1 vs 6.6§ 0.2 days, P=0.004) than the laparotomy group. All group patients didn’t require a blood transfusion. In multivariate analysis, there was no significant difference between laparoscopy and laparotomy group in obstetric outcomes, including preterm delivery and miscarriage rate, after adjusting for confounding factors, such as gestational age at surgery, emergency surgery and mass size. The median follow-up time was 3.5 years (range, 1.511.5 years). The median age of the child was 2.5 years (range, 1-9.5 years). All babies were healthy. Conclusion: In this retrospective study, the successful outcome suggests that operative laparoscopy for adnexal masses performed during pregnancy is safe and feasible when performed by experienced surgeons. Procedures in the second trimester without emergency indications is preferable.
Virtual Poster Session 1: Laparoscopy (10:00 AM — 10:10 AM) 10:00 AM: STATION K 2924 Oophoropexy in Adolescent Patients Gabra M,* Aguirre AG. University of Arizona, Tucson, AZ *Corresponding author. Video Objective: This video demonstrates a technique of oophoropexy through plication of the utero-ovarian ligament to the round ligament. Setting: The patient is a 13 year old P0 with a history of right ovarian torsion 10 months prior, for which she underwent laparoscopic detorsion without oophoropexy. She re-presented to the ED with two weeks of severe intermittent right lower abdominal pain, associated with nausea and vomiting. MRI abdomen/pelvis revealed twisting of the right ovarian pedicle. In addition, the right ovary was enlarged due to ovarian stromal edema, and there was peripheralization of the follicles. There was no ovarian cyst or mass. At the time of evaluation, the patient was not experiencing pain and she was clinically stable. She was suspected to have intermittent torsion. The patient and her parents were counseled on the option of observation and outpatient follow up versus surgical management with oophoropexy. They desired to proceed with surgical management. Interventions: Oophoropexy was performed with a horizontal mattress of non-absorbable Polyester suture from the round ligament, through the mesosalpinx, and to the utero-ovarian ligament. Conclusion: Evidence supports ovarian oophoropexy rather than oophorectomy for recurrent ovarian torsion in adolescents. Despite this the National Inpatient Sample (NIS) estimates 78% of adolescents underwent oophorectomy. We demonstrate a method of oophoropexy for recurrent ovarian torsion. The case patient has remained asymptomatic since her procedure. In conclusion, oophoropexy should be considered for adolescent patients with recurrent ovarian torsion to decrease risk of recurrence and to preserve fertility. Virtual Poster Session 1: Laparoscopy (10:00 AM — 10:10 AM) 10:00 AM: STATION L 2347 A Comparison of Laparoscopic Versus Laparotomy Management for Adnexal Masses During Pregnancy: A Retrospective Study With 16-Year Experience Li M*. Obstetrics and Gynecology, Affiliated of Beijing ChaoYang Hospital, Capital University of Medical Science, Beijing, China *Corresponding author. Study Objective: To evaluate the surgical, obstetric outcomes between laparoscopic and laparotomy management for adnexal mass during pregnancy. Design: Retrospective comparative study. Setting: University tertiary care referral center for endoscopic surgery.
Virtual Poster Session 1: Laparoscopy (10:00 AM — 10:10 AM) 10:00 AM: STATION M 2679 Management of a Large Uterus and its Complications to a Successful Laparoscopic Surgery Cervantes GV,1,* Ohara F,2 Tomasi MC,3 Ribeiro PA,2 Ribeiro HA2. 1 Laparoscopic Surgery and Endometriosis, Irmandade da Santa Casa de Miseric ordia de S~ ao Paulo, S~ ao Paulo, Brazil; 2Irmandade da Santa Casa de Miseric ordia de S~ ao Paulo, S~ ao Paulo, Brazil; 3Irmandade da Santa Casa de Miseric ordia de S~ ao Paulo, sao paulo, Brazil *Corresponding author. Video Objective: Present and demonstrate a pre operative and surgical management of large uterus and its complications. Setting: A 37-years-old, G2P2, who complained of progressive dysmenorrhea, genital pelvic and low-back pain without improvement with hormonal treatment. Complementary exams showed deep endometriosis on the posterior compartment, myomatosis uterus with 848cc of volume and an 139cc cystic right ovarian mass, which generated an extrinsically compression on the right ureter and ureterohydronephrosis. Interventions: Pre operative management consisted in double J catheter in the right ureter and uterine artery embolization with prophylactic antibiotic 3 months before the surgery. Final complementary exams showed an uterine volume reduction to 313cc. Laparoscopic treatment consisted of inspecting pelvic and abdominal cavities. Right ovarian mass was adhered to the posterior compartment including ovarian fossa, rectovaginal septum and right uterossacral ligament. Strategy consisted of right ovariectomy, Latsko and Okabayashi space dissection to identify bilateral hypogastric nerves and ureters. After identifying anatomy landmarks, endometriotic lesions were removed from uterossacral ligament and ureter. Rectovaginal septum was dissecated and bowel superficial lesion identified. Hysterectomy and bilateral salpingectomy were performed as treatment. Linear stapler was used to remove bowel endometriotic lesion. Ureterohydronephrosis became absent and controlled and Double J catheter was removed right after the surgery. Double J catheter right after surgery. Conclusion: Pre operative strategies are very important to a successful surgery. Double J catheter is a temporary intervention to prevent ureteres
S108
Abstracts / Journal of Minimally Invasive Gynecology 26 (2019) S98−S231
complications. Uterine artery embolization reduced more than 50% of the uterine volume. These strategies facilitated the access to the pelvis and promoted excellent laparoscopic view to completely treat myomatosis and deep endometriosis.
pregnancy. The myometrial lesion showed connection to the endometrial cavity. The site of removal was closed with interrupted polyglactin endosutures. The postoperative course was uneventful and the final pathologic report was an adenomyomatous polyp. Because the myometrial lesion showed connection to the endometrial cavity, hysteroscopic examination was performed after recovery, demonstrated a polypoid mass and a uterine septum. Hysteroscopic polypectomy was performed and the pathological diagnosis was also an adenomyomatous polyp. Conclusion: To our knowledge, this is the first report of an adenomyomatous polyp growing through the myometrial layer, into the pelvic cavity. Further study and a larger number of cases are needed to elucidate the mechanism which lies beneath the penetrating growth pattern of the adenomyomatous polyp into the myometrium.
Virtual Poster Session 1: Laparoscopy (10:00 AM — 10:10 AM) 10:00 AM: STATION N 1450 Laparoscopic Cornual Resection of Heterotopic Cornual Pregnancy Jiang L,* Chan-Tiopaianco M, Horng HC, Chen YJ, Wang PH. Obstetrics and Gynecology, Taipei Veteran General Hospital, Taipei, Taiwan *Corresponding author. Video Objective: Laparoscopic heterotopic cornual pregnancy resection. Setting: A 41 y/o woman, with history of G3P0E1(status post right salpingectomy)SA1 got pregnancy via IVF with frozen embryo transferred. Four embryos were transferred. However, at about gestational age 6 weeks, two intrauterine gestational sac and one right cornual gestational sac were found. All the fetus had heart beats. Thin uterine wall at right cornus about 0.53cm in size was also noticed. To preserve normal intrauterine pregnancy, surgical intervention was suggested, and the patient received laparoscopic cornual resection surgery. Interventions: During operation, to prevent fetus injury, we didn’t use uterine manipulator or pitressin injection. We also avoided electrical energy device to decrease thermal effect to fetus. Because of the rich blood flow of uterus, we hoped to decreased the surgical time, and barbed suture was used. Multiple suture layers for uterus was applied. We also used vaginal ultrasound during operation to check the uterine condition. After checking bleeders, adhesion barrier was used. For postoperative medication, progesterone was prescribed for tocolysis. We checked ultrasound after the surgery, and only one fetus with fetal heart beat was noticed. Conclusion: Laparoscopic heterotypic cornual pregnancy resection is feasible with the advantages of decreased hospital stay, less wound pain, and less use of analgesics. Further obstetrics outcome is reassuring in current studies. Virtual Poster Session 1: Laparoscopy (10:00 AM — 10:10 AM) 10:00 AM: STATION O 1402 Hemoperitoneum Caused by Ectopic Location of an Adenomyomatous Polyp Moon HS,* Koo JS, Nam GI. Obstetrics & Gynecology, Good Moonhwa Hospital, Busan, Korea, Republic of (South) *Corresponding author. Video Objective: To demonstrate an unusual case of hemoperitoneum caused by adenomyomatous polyps growing through the myometrial layer, into the pelvic cavity. Setting: An academic teaching hospital. Interventions: A 46-year-old woman was referred for postcoital abdominal pain for 3 days. Physical examination revealed both direct and rebound tenderness of the whole abdomen. Her vital signs were stable. The hemoglobin level was 12.7g/dL, CA-125 elevated to 80.3 U/ml (reference range, 0-35 U/ml) and serum b-hCG level below 1.2mIU/ml. Transvaginal ultrasound demonstrated free fluid in cul-de-sac. The initial clinical diagnosis was hemoperitoneum and she underwent operative laparoscopy. Approximately 500cc of blood and clots were pooled in the abdomino-pelvic cavity. A brown-colored soft lesion with an irregular surface was noted in the right cornua which was suspected to be a ruptured interstitial pregnancy. Removed tissue specimen was sent for frozen biopsy, of which result was endometrial tissue not related to
Virtual Poster Session 1: Laparoscopy (10:00 AM — 10:10 AM) 10:00 AM: STATION P 1787 A Case of Female Genital Tuberculosis with Superimposed Tubo-Ovarian Abscess in a Developed Nation Fowler ML,* O’Rourke-Suchoff D, Steer J, Noel NL, Hendessi P. Boston Medical Center, Boston, MA *Corresponding author. Video Objective: To describe the surgical techniques in a case of female genital tuberculosis (TB) with superimposed tubo-ovarian abscess (TOA) in a developed country. Setting: A 22-year-old G0 who was born in Vietnam presented to the emergency room with pelvic pain and known bilateral hydrosalpinx. She was treated for pelvic inflammatory disease, and a TB test was sent and later returned as positive. Her initial chest x-ray was read as normal. When she returned for follow up, a CT scan was planned to evaluate the extent of pulmonary and possible pelvic disease. However, before this could be done, she became febrile, requiring hospitalization with concern for TB or TOA. Interventions: Once pulmonary and peritoneal TB were suspected based on imaging, diagnosis of TB was attempted via sputum culture and endometrial biopsy. However, there was significant concern that the patient had a tubo-ovarian abscess given the high fevers, dilated tubes, and delay in urogenital TB diagnosis confirmation. This led to the patient being taken to the operating room for diagnostic laparoscopy and drainage of the tube. This video shows the techniques used to evaluate pelvic organs when acute infection is suspected. Ultimately, the endometrial biopsy returned positive for culture of Mycobacterium tuberculosis, confirming the diagnosis of female genital tuberculosis. Conclusion: This patient was diagnosed genital TB with superimposed bacterial infection, leading to the pyosalpinx. Female genital TB can cause a diagnostic challenge, and surgery may be required to achieve a diagnosis. Pre-operative planning and careful surgical technique is essential when faced with dense adhesions. Virtual Poster Session 1: Laparoscopy (10:00 AM — 10:10 AM) 10:00 AM: STATION Q 2932 Total Laparoscopic Hysterectomy: 5 Step Approach for Uteri Larger than 500 Grams Katebi Kashi P,* Hamilton CA. OB/GYN, Inova FairFax Hospital, Falls Church, VA *Corresponding author. Video Objective: To demonstrate a five step approach facilitating successful completion of Total Laparoscopic Hysterectomy (TLH) in patients with uteri larger than 500 grams.