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A Neuroanatomical Approach to the Resection of Peritoneal and Deeply Infiltrative Endometriosis
Abstracts / Journal of Minimally Invasive Gynecology 24 (2017) S1–S201 tacking the posterior bladder wall to the psoas muscle, is a key approach. Objective: To describe the robotic surgical management of bilateral UE. Clinical information: A 33 year-old G0 recurrent Stage IV endometriosis presented with bilateral ureteral strictures and infertility. Interventions: Robotic bilateral UCN with Psoas hitch after TLH with BSO. Results: No evidence of bilateral ureteral strictures and leak 2 month postoperative by CT-urogram. Conclusion: Key of successful management in bilateral ureteral endometriosis is following the principles of ureteroneocystostomy.
206
Video Session 1 – Robotics (11:00 AM - 12:00 PM) 11:21 AM – GROUP A
Diaphragmatic Endometriosis (DE) Surgical Techniques for the Right Side – What We Have Learned after 31 Cases Ribeiro DM,1 Rib GM,1 Santos TP,1 Chamie L,2 Serafini P,3 Weerbe E1. 1 Hospital São Luiz Morumbi, São Paulo, Brazil; 2Chamié Imagem da Mulher, São Paulo, Brazil; 3Clinica Huntington, São Paulo, Brazil Among thirty-one cases operated since 2007, we chose two that could represent the current techniques used for treating DE - even though all patients had excellent results, with no signs of recurrence of symptoms. We believe that ablation with any kind of energy is the gold standard treatment for superficial lesions with or without partial infiltration of diaphragmatic musculars. For the treatment of our patients laparoscopy robotic-assisted (LRA) technology was used. In cases where lesions were deep or had already caused fenestration in the diaphragm surface or that are affecting the central tendon of the diaphragm, we preferred resection followed by reconstruction, applying the video assisted thoracoscopy(VAT) technique associated with LRA. This video shows how to obtain maximum visualization of the diaphragmatic surface and the importance of VAT, avoiding iatrogenic nerve phrenic and vascular injuries, providing new information of others residual endometriotic lesions in the thoracic cavity.
Introduction: 56 year old G3P3 presents with recurrent vaginal vault prolapse and pelvic pain. She had a prior robotic sacrocolpopexy complicated by a subsequent right vesicovaginal fistula, which was repaired by performing a ureteral neocystostomy and partial takedown of the sacrocolpopexy. On exam, she had pain on palpation of mesh remaining at the apex of the vagina. Purpose/Methods: To demonstrate removal of painful mesh and correction of recurrent vaginal vault prolapse following right ureteral neocystotomy through robotic uterosacral ligament suspension (USLS). Results: Significantly improved pain and resolution of prolapse. Discussion/Conclusion: USLS was chosen in order to maintain the vaginal axis and avoid excessive tension on the right ureter, which was encased in adhesive scar tissue from the initial robotic sacrocolpopexy. Deviation of the vaginal axis posteriorly via sacrospinous ligament suspension may inadvertently lead to neoureteral obstruction. Partial removal of mesh was performed due to pain symptoms.
209
Robotic-Assisted Uterine Artery Ligation via the Posterior Approach for Huge Myomectomy Chang I, Liu W-M. Department of Obstetrics and Gynecology, Taipei Medical University Hospital, Taipei, Taiwan The objective of this video is to demonstrate the techniques and surgical landmarks of uterine artery ligation via the posterior approach in Robotic-assisted myomectomy. We present a case of a 38 year-old woman with a large myoma at the uterine fundus. The posterior approach was selected in this case because the myoma obstructed our access to the lateral approach. We will explain this approach step by step, combined with visual labels. Moreover, the benefits of uterine artery ligation will be discussed briefly.
Video Session 1 – Robotics (11:00 AM - 12:00 PM) 11:32 AM – GROUP B
Uterus Transplantation: Robotic Surgeon Perspective Fornalik H, Fornalik N. Surgical Oncology, Goshen Center for Cancer Care, Goshen, Indiana We demonstrate dissection of deep uterine vessels during robotic radical nervesparing hysterectomy. We discuss advantages and disadvantages of utilization of robotic platform for deep pelvic surgery. Potential benefits of adaptation of robotic technique to uterine harvesting from live donor are discussed. Relevant aspects of anatomy and modifications to technique of uterine harvesting to enhance transplant vasculature are demonstrated. Level of experience and skill set needed for likely success are discussed. The tutorial is enhanced by diagrams.
Video Session 1 – Robotics (11:00 AM - 12:00 PM) 11:46 AM – GROUP B
210 207
S85
Video Session 1 – Robotics (11:00 AM - 12:00 PM) 11:53 AM – GROUP B
Patient-Specific Approach to Positioning during Robotic Surgery Chandler J, Mihalov LS. Virginia Mason Medical Center, Seattle, Washington The objective of our video is to demonstrate the patient-specific approach to Trendelenburg positioning for robotic-assisted pelvic surgeries in our institution. Robotic-assisted pelvic surgery is typically performed with the patient in steep Trendelenburg, or an incline of 20–30 degrees. The negative physiologic impact of steep Trendelenburg has been demonstrated in a number of studies. Our technique limits the degree of incline to the amount needed to provide adequate exposure to the target anatomy.
TUESDAY, NOVEMBER 14, 2017 208
Video Session 1 – Robotics (11:00 AM - 12:00 PM)
211
Video Session 2 – Endometriosis (12:10 PM - 1:10 PM)
11:39 AM – GROUP B Robotic Uterosacral Ligament Suspension Following Ureteral Neocystotomy Mehandru N,1 Yi J2. 1Advanced Gynecology Surgery and Pelvic Pain, Dignity Health-St. Joseph’s Hospital and Medical Center, Phoenix, Arizona; 2Department of Medical and Surgical Gynecology, Mayo Clinic Hospital-Phoenix, Phoenix, Arizona
12:10 PM – GROUP A A Neuroanatomical Approach to the Resection of Peritoneal and Deeply Infiltrative Endometriosis Hudgens JL,1 Cooper JA,1 Lang TG,2 Pasic RP2. 1Department of Ob/Gyn, University of Mississippi, Jackson, Mississippi; 2Department of Ob/Gyn, University of Louisville, Louisville, Kentucky
S86
Abstracts / Journal of Minimally Invasive Gynecology 24 (2017) S1–S201
The purpose of this video is to present the neuroanatomical location of the plexus pelvinus (inferior hypogastric plexus), Superior hypogastric nervers and the postganglionic sympathetic nerve fibers. We will also demonstrate how to apply this knowledge to the nerve-sparing resection of peritoneal and deeply infiltrative endometriosis.
We believe that in patients with endometriosis, removal of affected tissue is an important part of treatment, with or without hysterectomy. We demonstrate efficient technique for removing affected peritoneum in the setting of a total laparoscopic hysterectomy. Ureteral and parametric anatomy are demonstrated, as well as appropriate dissection technique.
212
215
Video Session 2 – Endometriosis (12:10 PM - 1:10 PM) 12:17 PM – GROUP A
Bladder Endometriosis: Surgical Principles Lozada Y, Ghazi A, Carrillo JF. Obstetrics and Gynecology, University of Rochester School of Medicine and Dentistry, Rochester, New York Urinary tract endometriosis is uncommon but can significantly impact patient’s quality of life. It affects approximately 1 % of women with this disease. The bladder is the most commonly affected urinary tract site. Patients often present with bothersome urinary tract symptoms that may mimic interstitial cystitis or a persistent infection. Although medical treatment has been described, the benefits are short-lived. Surgical resection of bladder lesions has been shown to be superior for symptom alleviation and has less risk of recurrence. Our video describes important pearls and perioperative considerations to keep in mind when surgically treating bladder endometriosis (BE). Three patients who underwent robotic partial cystectomy are presented. We emphasize the importance of comprehensive anatomic knowledge, and the proper technique for resection of bladder lesions. We also provide a meticulous yet concise stepwise guide for effectively managing patients with BE.
213
Video Session 2 – Endometriosis (12:10 PM - 1:10 PM)
Video Session 2 – Endometriosis (12:10 PM - 1:10 PM) 12:42 PM – GROUP B
Resection of Isolated Bladder Endometriosis Spadoto-Dias D,1 Bueloni-Dias FN,1 Leite NJ,1 Modotti CC,2 Modotti WP2. 1Gynecology and Obstetrics, Botucatu Medical School, Sao Paulo State University - FMB/UNESP, Botucatu, Sao Paulo, Brazil; 2 Instituto de Atendimento Médico-Hospitalar - IAM, Assis, Sao Paulo, Brazil We present the case of a 43-year-old woman with two previous c-sections and a history of low pelvic pain in the last three years, associated with dysuria and macroscopic hematuria during the menstrual period. A NMR revealed a focus of endometriotic aspect affecting the bladder wall on the trine topography measuring 3.0 cm in the largest diameter. Cystoscopy revealed bluish nodules affecting the posterior wall of the bladder extending from the bladder dome to the trine. Bilateral catheterization of ureters was performed previously the procedure. Resection with 5 mm cold scissors and rotating bipolar forceps was performed carefully until complete removal of the lesion. Surgical treatment of urinary tract endometriosis should be individualized, since its isolated manifestation is extremely rare. Indicatives of impaired urinary tract may be cyclic dysuria, urge incontinence, hematuria. Identification of ureteral ostiums and placement of JJ stents may be necessary for security improvements during the procedure.
12:24 PM – GROUP A Peritoneal Pockets: Tips for Complete Excision Stuparich MA, Lee TTM. Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens Hospital of UPMC, Pittsburgh, Pennsylvania
216
Pelvic peritoneal pockets were first described in 1927 and are also known as Allen-Masterson pockets, Allen-Masterson windows, or deep retraction pockets. Two leading theories exist to explain their formation. First, the pockets may result from peritoneal irritation or invasion by endometriosis that causes scarring and retraction. Alternatively, a retraction pocket may exist primarily and endometriosis may grow on the altered peritoneal surface. Peritoneal pockets should be excised when visualized. Knowledge of the anatomy in the pocket location is imperative as complete pocket removal may require ureterolysis or mobilization of the bowel. The lesion should be circumscribed as anatomy and pathology allow. Traction and countertraction as well as constant tissue manipulation with the assisting hand increase the efficiency of dissection. Maintenance of hemostasis is important to prevent obscuring of tissue planes.
Minimizing Ovarian Damage When Resecting Endometriomas Zakhari A,1 Papillon-Smith J,2 Solnik MJ,2 Murji A2. 1McGill University Health Centre, Montreal, Quebec, Canada; 2Mt. Sinai Hospital, Toronto, Ontario, Canada
214
Video Session 2 – Endometriosis (12:10 PM - 1:10 PM)
12:49 PM – GROUP B
Endometriomas are commonly encountered in clinical practice, and at times resection is warranted for patients seeking fertility or who are symptomatic from their presence. A desire to definitively resect the lesion is often tempered with concern over excessive collateral damage to healthy ovarian tissue during surgery. Several surgical techniques can be employed to minimize damage to surrounding normal tissue while ensuring adequate hemostasis. These techniques include the use of dilute injectable vasopressin, endoloop closure of raw ovarian edges, hemostatic agents such as Surgiflo or Surgicel, suturing the ovary, and focused bipolar electrocautery.
217 12:31 PM – GROUP A Laparoscopic Hysterectomy with Extended Peritonectomy for Endometriosis Fogelson NS, Rosenfield R. Pearl Women’s Center, Portland, Oregon This video demonstrates technique for performing a bilateral pelvic sidewall peritonectomy as part of a total laparoscopic hysterectomy, in the setting of extensive stage 1 endometriosis. The patient is a 42 year old G2P1 with a history of multiple ablative surgeries for endometriosis and pelvic pain. She has persistent dysmennoreah and is seeking definitive treatment.
Video Session 2 – Endometriosis (12:10 PM - 1:10 PM)
Video Session 2 – Endometriosis (12:10 PM - 1:10 PM) 12:56 PM – GROUP B
Endometriosis and Uterine Anomalies Melnyk A, Rindos N, Lee TTM. Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens Hospital of UPMC, Pittsburgh, Pennsylvania The purpose of this video is to review the management of endometriosis in the setting of uterine anomalies. A patient with a uterine anomaly has a
206
Video Session 1 – Robotics (11:00 AM - 12:00 PM) 11:21 AM – GROUP A
Diaphragmatic Endometriosis (DE) Surgical Techniques for the Right Side – What We Have Learned after 31 Cases Ribeiro DM,1 Rib GM,1 Santos TP,1 Chamie L,2 Serafini P,3 Weerbe E1. 1 Hospital São Luiz Morumbi, São Paulo, Brazil; 2Chamié Imagem da Mulher, São Paulo, Brazil; 3Clinica Huntington, São Paulo, Brazil Among thirty-one cases operated since 2007, we chose two that could represent the current techniques used for treating DE - even though all patients had excellent results, with no signs of recurrence of symptoms. We believe that ablation with any kind of energy is the gold standard treatment for superficial lesions with or without partial infiltration of diaphragmatic musculars. For the treatment of our patients laparoscopy robotic-assisted (LRA) technology was used. In cases where lesions were deep or had already caused fenestration in the diaphragm surface or that are affecting the central tendon of the diaphragm, we preferred resection followed by reconstruction, applying the video assisted thoracoscopy(VAT) technique associated with LRA. This video shows how to obtain maximum visualization of the diaphragmatic surface and the importance of VAT, avoiding iatrogenic nerve phrenic and vascular injuries, providing new information of others residual endometriotic lesions in the thoracic cavity.
Introduction: 56 year old G3P3 presents with recurrent vaginal vault prolapse and pelvic pain. She had a prior robotic sacrocolpopexy complicated by a subsequent right vesicovaginal fistula, which was repaired by performing a ureteral neocystostomy and partial takedown of the sacrocolpopexy. On exam, she had pain on palpation of mesh remaining at the apex of the vagina. Purpose/Methods: To demonstrate removal of painful mesh and correction of recurrent vaginal vault prolapse following right ureteral neocystotomy through robotic uterosacral ligament suspension (USLS). Results: Significantly improved pain and resolution of prolapse. Discussion/Conclusion: USLS was chosen in order to maintain the vaginal axis and avoid excessive tension on the right ureter, which was encased in adhesive scar tissue from the initial robotic sacrocolpopexy. Deviation of the vaginal axis posteriorly via sacrospinous ligament suspension may inadvertently lead to neoureteral obstruction. Partial removal of mesh was performed due to pain symptoms.
209
Robotic-Assisted Uterine Artery Ligation via the Posterior Approach for Huge Myomectomy Chang I, Liu W-M. Department of Obstetrics and Gynecology, Taipei Medical University Hospital, Taipei, Taiwan The objective of this video is to demonstrate the techniques and surgical landmarks of uterine artery ligation via the posterior approach in Robotic-assisted myomectomy. We present a case of a 38 year-old woman with a large myoma at the uterine fundus. The posterior approach was selected in this case because the myoma obstructed our access to the lateral approach. We will explain this approach step by step, combined with visual labels. Moreover, the benefits of uterine artery ligation will be discussed briefly.
Video Session 1 – Robotics (11:00 AM - 12:00 PM) 11:32 AM – GROUP B
Uterus Transplantation: Robotic Surgeon Perspective Fornalik H, Fornalik N. Surgical Oncology, Goshen Center for Cancer Care, Goshen, Indiana We demonstrate dissection of deep uterine vessels during robotic radical nervesparing hysterectomy. We discuss advantages and disadvantages of utilization of robotic platform for deep pelvic surgery. Potential benefits of adaptation of robotic technique to uterine harvesting from live donor are discussed. Relevant aspects of anatomy and modifications to technique of uterine harvesting to enhance transplant vasculature are demonstrated. Level of experience and skill set needed for likely success are discussed. The tutorial is enhanced by diagrams.
Video Session 1 – Robotics (11:00 AM - 12:00 PM) 11:46 AM – GROUP B
210 207
S85
Video Session 1 – Robotics (11:00 AM - 12:00 PM) 11:53 AM – GROUP B
Patient-Specific Approach to Positioning during Robotic Surgery Chandler J, Mihalov LS. Virginia Mason Medical Center, Seattle, Washington The objective of our video is to demonstrate the patient-specific approach to Trendelenburg positioning for robotic-assisted pelvic surgeries in our institution. Robotic-assisted pelvic surgery is typically performed with the patient in steep Trendelenburg, or an incline of 20–30 degrees. The negative physiologic impact of steep Trendelenburg has been demonstrated in a number of studies. Our technique limits the degree of incline to the amount needed to provide adequate exposure to the target anatomy.
TUESDAY, NOVEMBER 14, 2017 208
Video Session 1 – Robotics (11:00 AM - 12:00 PM)
211
Video Session 2 – Endometriosis (12:10 PM - 1:10 PM)
11:39 AM – GROUP B Robotic Uterosacral Ligament Suspension Following Ureteral Neocystotomy Mehandru N,1 Yi J2. 1Advanced Gynecology Surgery and Pelvic Pain, Dignity Health-St. Joseph’s Hospital and Medical Center, Phoenix, Arizona; 2Department of Medical and Surgical Gynecology, Mayo Clinic Hospital-Phoenix, Phoenix, Arizona
12:10 PM – GROUP A A Neuroanatomical Approach to the Resection of Peritoneal and Deeply Infiltrative Endometriosis Hudgens JL,1 Cooper JA,1 Lang TG,2 Pasic RP2. 1Department of Ob/Gyn, University of Mississippi, Jackson, Mississippi; 2Department of Ob/Gyn, University of Louisville, Louisville, Kentucky
S86
Abstracts / Journal of Minimally Invasive Gynecology 24 (2017) S1–S201
The purpose of this video is to present the neuroanatomical location of the plexus pelvinus (inferior hypogastric plexus), Superior hypogastric nervers and the postganglionic sympathetic nerve fibers. We will also demonstrate how to apply this knowledge to the nerve-sparing resection of peritoneal and deeply infiltrative endometriosis.
We believe that in patients with endometriosis, removal of affected tissue is an important part of treatment, with or without hysterectomy. We demonstrate efficient technique for removing affected peritoneum in the setting of a total laparoscopic hysterectomy. Ureteral and parametric anatomy are demonstrated, as well as appropriate dissection technique.
212
215
Video Session 2 – Endometriosis (12:10 PM - 1:10 PM) 12:17 PM – GROUP A
Bladder Endometriosis: Surgical Principles Lozada Y, Ghazi A, Carrillo JF. Obstetrics and Gynecology, University of Rochester School of Medicine and Dentistry, Rochester, New York Urinary tract endometriosis is uncommon but can significantly impact patient’s quality of life. It affects approximately 1 % of women with this disease. The bladder is the most commonly affected urinary tract site. Patients often present with bothersome urinary tract symptoms that may mimic interstitial cystitis or a persistent infection. Although medical treatment has been described, the benefits are short-lived. Surgical resection of bladder lesions has been shown to be superior for symptom alleviation and has less risk of recurrence. Our video describes important pearls and perioperative considerations to keep in mind when surgically treating bladder endometriosis (BE). Three patients who underwent robotic partial cystectomy are presented. We emphasize the importance of comprehensive anatomic knowledge, and the proper technique for resection of bladder lesions. We also provide a meticulous yet concise stepwise guide for effectively managing patients with BE.
213
Video Session 2 – Endometriosis (12:10 PM - 1:10 PM)
Video Session 2 – Endometriosis (12:10 PM - 1:10 PM) 12:42 PM – GROUP B
Resection of Isolated Bladder Endometriosis Spadoto-Dias D,1 Bueloni-Dias FN,1 Leite NJ,1 Modotti CC,2 Modotti WP2. 1Gynecology and Obstetrics, Botucatu Medical School, Sao Paulo State University - FMB/UNESP, Botucatu, Sao Paulo, Brazil; 2 Instituto de Atendimento Médico-Hospitalar - IAM, Assis, Sao Paulo, Brazil We present the case of a 43-year-old woman with two previous c-sections and a history of low pelvic pain in the last three years, associated with dysuria and macroscopic hematuria during the menstrual period. A NMR revealed a focus of endometriotic aspect affecting the bladder wall on the trine topography measuring 3.0 cm in the largest diameter. Cystoscopy revealed bluish nodules affecting the posterior wall of the bladder extending from the bladder dome to the trine. Bilateral catheterization of ureters was performed previously the procedure. Resection with 5 mm cold scissors and rotating bipolar forceps was performed carefully until complete removal of the lesion. Surgical treatment of urinary tract endometriosis should be individualized, since its isolated manifestation is extremely rare. Indicatives of impaired urinary tract may be cyclic dysuria, urge incontinence, hematuria. Identification of ureteral ostiums and placement of JJ stents may be necessary for security improvements during the procedure.
12:24 PM – GROUP A Peritoneal Pockets: Tips for Complete Excision Stuparich MA, Lee TTM. Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens Hospital of UPMC, Pittsburgh, Pennsylvania
216
Pelvic peritoneal pockets were first described in 1927 and are also known as Allen-Masterson pockets, Allen-Masterson windows, or deep retraction pockets. Two leading theories exist to explain their formation. First, the pockets may result from peritoneal irritation or invasion by endometriosis that causes scarring and retraction. Alternatively, a retraction pocket may exist primarily and endometriosis may grow on the altered peritoneal surface. Peritoneal pockets should be excised when visualized. Knowledge of the anatomy in the pocket location is imperative as complete pocket removal may require ureterolysis or mobilization of the bowel. The lesion should be circumscribed as anatomy and pathology allow. Traction and countertraction as well as constant tissue manipulation with the assisting hand increase the efficiency of dissection. Maintenance of hemostasis is important to prevent obscuring of tissue planes.
Minimizing Ovarian Damage When Resecting Endometriomas Zakhari A,1 Papillon-Smith J,2 Solnik MJ,2 Murji A2. 1McGill University Health Centre, Montreal, Quebec, Canada; 2Mt. Sinai Hospital, Toronto, Ontario, Canada
214
Video Session 2 – Endometriosis (12:10 PM - 1:10 PM)
12:49 PM – GROUP B
Endometriomas are commonly encountered in clinical practice, and at times resection is warranted for patients seeking fertility or who are symptomatic from their presence. A desire to definitively resect the lesion is often tempered with concern over excessive collateral damage to healthy ovarian tissue during surgery. Several surgical techniques can be employed to minimize damage to surrounding normal tissue while ensuring adequate hemostasis. These techniques include the use of dilute injectable vasopressin, endoloop closure of raw ovarian edges, hemostatic agents such as Surgiflo or Surgicel, suturing the ovary, and focused bipolar electrocautery.
217 12:31 PM – GROUP A Laparoscopic Hysterectomy with Extended Peritonectomy for Endometriosis Fogelson NS, Rosenfield R. Pearl Women’s Center, Portland, Oregon This video demonstrates technique for performing a bilateral pelvic sidewall peritonectomy as part of a total laparoscopic hysterectomy, in the setting of extensive stage 1 endometriosis. The patient is a 42 year old G2P1 with a history of multiple ablative surgeries for endometriosis and pelvic pain. She has persistent dysmennoreah and is seeking definitive treatment.
Video Session 2 – Endometriosis (12:10 PM - 1:10 PM)
Video Session 2 – Endometriosis (12:10 PM - 1:10 PM) 12:56 PM – GROUP B
Endometriosis and Uterine Anomalies Melnyk A, Rindos N, Lee TTM. Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens Hospital of UPMC, Pittsburgh, Pennsylvania The purpose of this video is to review the management of endometriosis in the setting of uterine anomalies. A patient with a uterine anomaly has a