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Journal of Minimally Invasive Gynecology, Vol 12, No 5, September/October Supplement 2005

FRIDAY, NOVEMBER 11, 2005 (4:27 PM– 4:33 PM) Open Communications 6 —Operative Laparoscopy 279 The Role of Robotic-Assisted Laparoscopy in Gynecological Surgeries Saberi NS, Shahmohamady B, Nezhat CH, Nezhat F, Nezhat C. Foster City, California; Palo Alto, California; Palo Alto, California; Palo Alto, California; The Center for Minimally Invasive Surgery, Palo Alto, California Study Objective: To evaluate the role of robotic-assisted laparoscopy in gynecological surgeries Design: Retrospective study Setting: Tertiary referral center Patients: Women of different age group who were undergoing laparoscopy surgeries Intervention: In a tertiary referral center for laparoscopic gynecological surgery, a total of 15 patients who were undergoing various gynecologic surgeries were consented for combined laparoscopic and robotic-assisted laparoscopic surgery. The da Vinci robot was used for each case. Four ports were inserted: umbilicus, suprapubic, and two lateral ports. These surgeries were performed both using laparoscopic and robotic-assisted laparoscopic techniques. Measurements and Main Results: Fifteen patients underwent a variety of gynecologic surgeries such as myomectomies, treatment of endometriosis, total and supracervical hysterectomy, ovarian cystectomy, sacral colpopexy and Moskowitz procedure. The assembly time to switch from laparoscopy to robotic assisted surgery was 18.9 minutes (14-27 minutes), and the disassembly time was 2.1 minutes (1–3 minutes). Robotic assisted surgery was used for suturing after myomectomy, tissue manipulation, suturing of cervical stump after supracervical hysterectomy, vaginal cuff closure and suspension after total laparoscopic hysterectomy, ovarian suturing after cystectomy and performing Moskowitz procedure. Conclusion: Robotic-assisted laparoscopic surgeries have advantages in providing a 3 dimensional visualization of operative field, decreasing fatigue and tension tremor of surgeon, and added wrist motion for improved dexterity and greater surgical precision. The disadvantages include enormous cost and added operating time for assembly and disassembly. The greatest practical use lies in the ability to perform easier suturing in laparoscopic surgery. FRIDAY, NOVEMBER 11, 2005 (3:45 PM) Open Communications 7—Endometriosis 280 Endometriosis in Women with Symptomatic Leiomyomata Saberi NS. Foster City, California Study Objective: To determine the presence of endometriosis in patients with symptomatic leiomyomata

Design: Retrospective study. Setting: Tertiary referral endoscopic center. Patients: Premenopausal patients with symptomatic fibroid. Intervention: This was a retrospective chart review from January 2002 through June 2004 from a tertiary referral endoscopic center. Premenopausal patients were selected who had symptomatic leiomyomata and were candidates for surgical therapy. Patients underwent laparoscopic myomectomy or laparoscopic assisted myomectomy. Patients were included if they had symptoms such as pressure, menorrhagia, pelvic pain, or dysmenorrhea, with ultrasound findings or operative findings consistent with significant leiomyomata. Endometriosis was verified by biopsy or laparoscopic inspection and photographic documentation by an experienced surgeon. Measurements and Main Results: A total of 32 patients met the inclusion criteria. Average age was 40.5 (27–50) years. The sizes of leiomyomata were reported either as weight in grams or in dimensions of the collective morcellated leiomyomata. Among 25 patients the average weight of the leiomyomata was 319 g (35–1650g). The remaining 7 patients had size reported as the dimensions of the collective morcellated leiomyomata, which were on average 9.4x8.5 cm. Twenty-seven of the 32 (84%) patients were found to have concurrent endometriosis. All 27 patients had photographic documentation. Fourteen of the 27 patients had excisional biopsy confirming endometriosis. Conclusion: Our data suggest that a high percentage of patients with leiomyomata have endometriosis. 281 Identification of Remarkable Complication during Retroperitoneal Laparoscopic Lymphadenectomy against Gynecologic Cancer Sasaki H, Hoshiba T, Asamoto A, Hirabuki SY, Ishikawa H, Yoshinari H, Saitoh R. Ishikawa Prefectural Central Hospital, Kanazawa, Ishikawa, Japan Study Objective: To identify procedure-specific complication during retroperitoneal laparoscopic lymphadenectomy, and to discuss the safety measure against those complications. Design: Retrospective review of 86 cases with gynecologic cancer who underwent retroperitoneal laparoscopic paraaortic/pelvic lymphadenectomy. Setting: Urban group practice in Kanazawa, Japan. Patients: Eighty-six women who required para-aortic/pelvic lymphadenectomy due to gynecologic cancer. Intervention: Retroperitoneal laparoscopic para-aortic/pelvic lymphadenectomy. Measurements and Main Results: Four cases were unexpectedly required laparotomy. Two pneumothoraces were found during retroperitoneal lymphadenectomy, and these were seemed to be independent to the learning curve. Sudden drop of SpO2 was the initial sign on diagnosis of

Posters intraoperative pneumothorax in both cases, although variability of SpO2, PaCO2, and ETCO2 seemed to be unreliable. Two unexpected hemorrhages were encountered in the early cases; however, it could be manageable after we had gained further laparoscopic skills. Conclusion: Complications of laparoscopic surgery were divided into two categories; (i) manageable by developing skills, and (ii) unpredictable. Intraoperative pneumothorax might be one of the unpredictable complications. Pneumoretroperitoneal approach would be more susceptible to intraoperative pneumothorax than conventional pneumoperitoneal laparoscopy.

S111 anatomic characteristics of the adnexa after hysterectomy and the decreased potential for scarring after laparoscopic surgery. Methods including prophylactic oophoropexy which may prevent adnexal torsion at the time of laparoscopic hysterectomy are discussed in context. Conclusion: As laparoscopic hysterectomy becomes a more frequently performed procedure, so to will the complications which may accompany it. We believe that a greater awareness of potential complications combined with appropriate prophylactic measures at the time of hysterectomy may maintain the high degree of safety expected with laparoscopic procedures and prevent the possibility of certain complications such as adnexal torsion.

282 Bilateral Adnexal Torsion after Laparoscopic Vaginal Hysterectomy Sharma S, Gocial B. Philadelphia, Pennsylvania; The Women’s Institute for Fertility Endocrinology and Menopause, Philadelphia, Pennsylvania

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Study Objective: To identify a clinical situation where the potential development of adnexal torsion might be recognized and subsequently avoided. Design: Case report of simultaneous bilateral ovarian torsion following laparoscopically assisted vaginal hysterectomy with review of the literature. Setting: Women undergoing laparoscopic forms of hysterectomy with preservation of at least one adnexae. An individual case performed at Thomas Jefferson University Hospital, Philadelphia, PA in which subsequent bilateral adnexal torsion is described. Patients: A 42 year old patient (EFF) underwent an uncomplicated LAVH in June 2004 for menorrhagia. In February 2005, she developed pelvic pain prompting a total of three ER visits. On each occasion, she was managed conservatively as there were no acute changes. The pain remained at a significant level however prompting surgical evaluation and intervention. Intervention: Bilateral salpingo-oophorectomy for simultaneous adnexal torsion performed. Alternative options of detorsion and conservative management are considered and discussed with specific attention paid to intraoperative evaluation of anatomic features which may predispose to subsequent adnexal torsion. Measurements and Main Results: We report a case of simultaneous bilateral adnexal torsion after laparoscopic hysterectomy. Adnexal torsion is an unusual event accounting for approximately 3% of all emergency gynecologic surgery. It is most often reported in association with ovarian pathology as well as in pediatric populations. Mashiach et al (2004) described an incidence of unilateral torsion as high as 7.91/1000 in post laparoscopic hysterectomy patients. After review of the literature, we believe this is the first case of bilateral adnexal torsion after laparoscopic hysterectomy documented in the United States. Features are presented which may predispose towards adnexal torsion including

Study Objective: To assess surgical outcome and patient satisfaction following laparoscopic vaginal vault suspension using Pelvichol for treatment of pelvic support defects. Design: Retrospective review with questionnaire and follow up exam of 14 cases of laparoscopic vaginal vault suspension. Setting: Southeastern university-based tertiary care teaching hospital. Patients: Fourteen women (ages 39-74 yrs) with pelvic support defects. Intervention: Laparoscopic vaginal vault suspension using Pelvichol. Measurements and Main Results: Post-surgical examinations demonstrated significant improvement in all patients based on Baden-Walker classification. All patients maintained vaginal length of at least 10 centimeters. The mean follow up was 13.8 months (R 1.5–31.0). There was one recurrence of cystocele in a patient with otherwise significant improvement in rectocele and enterocele. Another patient required reoperation for cuff detachment from the graft material. All other follow up exams were stage 0. A telephone survey was conducted to assess patient perception of outcome. Eleven of 14 patients (78.5%) felt significant “pelvic pressure” prior to surgery. Of those 11, only 2 (18.2%) still identified “pelvic pressure” after surgery. Twenty-one and four-tenths percent of patients reported difficulties with sexual intercourse prior to surgery. In 50% of all patients surveyed felt that their sexual function improved as a direct result of their procedure. Using a ten point scale with one being “strongly disagree” and ten being “strongly agree”, the statement “I am very satisfied with my outcome” elicited a mean score of 8.6. In addition, the statement “I would recommend this surgery to a friend” elicited a mean score of 9.6. Conclusion: Laparoscopic vaginal vault suspension using Pelvichol graft material yields objective success with im-

Patient Satisfaction and Outcomes of Laparoscopic Vaginal Vault Suspension Using Pelvichol Grafts Storck KL, Jarnigan B. Nashville, Tennessee; Vanderbilt Medical Center, Nashville, Tennessee