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A Peculiar Vascular Injury in Robotic Hysterectomy
Abstracts / Journal of Minimally Invasive Gynecology 18 (2011) S169–S178 610 Sacrocolpopexy Take 2 Eigg MH. OB/GYN, Rochester General Hospital, Rochester, New York This is a MIS reoperation after a failed ASC done by laparotomy using Gortex/PTFE mesh. The prior detachment from the vaginal side of the repair can be seen and is addressed. Despite the prior open ASC we chose to proceed with laparoscopy and Robotics with a clean dissection and optimal visualization and mesh placement. This robotic repeat sacrocolpopexy demonstrates marked postoperative bowel adhesions, the decision to use a bridgeing large pore polypropelene mesh attaching to the prior placed PTFE mesh well fixed to the sacrum. It also demonstrates the placement of the new dissection and mesh into a retroperitoneal location.
611 A Peculiar Vascular Injury in Robotic Hysterectomy Elsahwi KS, Raji R, Azodi M. Obstetrics, Gynecology & Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut Objectives: presentation Results: This video shows an injury to the right external iliac vein during vaginal extraction of the uterus after completion of a robotic-assisted hysterectomy. A uterine manipulator had not been used, and upon trying to reach the 16-week size fibroid uterus with a single-toothed tenaculum introduced through the vagina, the right external iliac vein was inadvertently pierced. The robot was used to disengage the tenaculum and repair the vein. The case was not converted and the patient suffered no short or long term squeals. Conclusion: The tips of all instruments should be always kept in full view. Consistent adherence to the rules of laparoscopy prevents untoward consequences.
612 Robot-Assisted Laparoscopic Trachelectomy for Adenomyosis Gargiulo AR,1 Istre O,2 Divya S,1 Srouji SS.1 1Center for Infertility and Reproductive Surgery, Brigham and Women’s Hospital/Harvard Medical School, Boston, Massachusetts; 2Center for Minimally Invasive Gynecologic Surgery, Brigham and Women’s Hospital/Harvard Medical School, Boston, Massachusetts This video describes our technique of robot-assisted laparoscopic trachelectomy in a case of symptomatic adenomyosis of the cervical stump in a patient with prior supracervical hysterectomy. Robot-assisted laparoscopic trachelectomy is a safe and simple procedure that should be part of the armamentarium of the gynecologist at a time when the supracervical hysterectomy is gaining popularity.
613 Robotic Applications in Benign Adnexal Pathology Gargiulo AR, Shah D, Srouji SS. Center for Infertility and Reproductive Surgery, Brigham and Women’s Hospital/Harvard Medical School, Boston, Massachusetts This video illustrates our recent surgical experience with two separate cases of benign tumors of the adnexa. A 22 year old nulliparous woman was referred to us for a presumably benign solid tumor of the infundibulum. We performed a robot-assisted intact enucleation of the tumor with microsurgical instrumentation and complete preservation of the lumen. A 30 year old nulliparous and woman with previous laparoscopic stripping of mature teratomata was referred to us for a recurrence in the right ovary observed in preparation for an ART cycle. We performed a robot-assisted
S177
laparoscopic stripping entirely in a specimen pouch with no spill and with sparing of normal ovarian tissue and hilar vessels. In both of these cases the use of the da Vinci robot was felt to contribute distinct advantages in terms of fertility preservation over our standard laparoscopic techniques.
614 Myomectomy and Adenomyomectomy in Single Patient Using the DaVinci Robotic Green MA, DellaBadia C. OB/GYN, Drexel University College of Medicine, Philadelphia, Pennsylvania Video case presention of a 42 year-old woman with 7 cm posterior adenomyoma and 8 cm myoma on MRI. She desires to maintain her fertility and requested a myomectomy. The advantages of robotic technology are demonstrated including improved vision, articulation for meticulous movements, facilitation of dissection, enuculeation and suturing. We show the difference between excision of a myoma with discrete tissue planes and the more technically difficulty adenomyoma where the tissues planes are indistinct.
615 Robotic Sacrocolpopexy with Rectopexy for the Combined Treatment of Severe Pelvic Organ Prolapse Guan X, Zurawin RK. Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas The patient is a 70-year-old female with a previous total abdominal hysterectomy presenting with vaginal prolapse and fecal incontinence. Her rectocele protruded to the introitus with apical vaginal descent. Colorectal surgery consultation confirmed a high rectal prolapse and associated enterocele. Laparoscopic sacrocolpopexy with concomitant rectopexy treats both the rectal and vaginal prolapse, offers good functional outcome compared with open surgery and results in less postoperative pain and faster convalescence. This combined procedure entails a high level of surgical skill and knowledge of pelvic anatomy and is facilitated by the use of the robot. Robotic sacrocolpopexy with rectopexy is a feasible and safe procedure with minimal operative morbidity for the combined treatment of rectal and pelvic organ prolapse.
616 Robotic Assisted Laparoscopic Removal of the Retained Ovary Orady ME. Obstetrics, Gynecology, and Women’s Health, Henry Ford Health System, Detroit, Michigan Extensive pelvic adhesions can make removal of retained ovaries challenging. Enhanced 3-dimensional vision and increased precision and dexterity of daVinci robotic instrumentation allows for easier dissection of extensive adhesions for delineation of difficult anatomy. This video illustrates the precise dissection made possible using daVinci assistance for laparoscopic removal of retained ovaries in a 60 year old female with a previous history of multiple abdominal surgeries, including an abdominal hysterectomy performed for endometriosis. She presented with complaints of pelvic discomfort. Evaluation revealed a slowly enlarging complex 11x8x9 cm ovarian mass with normal tumor markers. Given the expectations of extensive adhesions and difficult removal of the large retained ovary intactpatient was offered a robotic assisted laparoscopic oophorectomy. This approach for efficient and safe removal of this enlarged ovary in a minimally invasive manner is outlined. The dissection of the retroperitoneal space and techniques of removing the ovary laparoscopically are discussed.
611 A Peculiar Vascular Injury in Robotic Hysterectomy Elsahwi KS, Raji R, Azodi M. Obstetrics, Gynecology & Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut Objectives: presentation Results: This video shows an injury to the right external iliac vein during vaginal extraction of the uterus after completion of a robotic-assisted hysterectomy. A uterine manipulator had not been used, and upon trying to reach the 16-week size fibroid uterus with a single-toothed tenaculum introduced through the vagina, the right external iliac vein was inadvertently pierced. The robot was used to disengage the tenaculum and repair the vein. The case was not converted and the patient suffered no short or long term squeals. Conclusion: The tips of all instruments should be always kept in full view. Consistent adherence to the rules of laparoscopy prevents untoward consequences.
612 Robot-Assisted Laparoscopic Trachelectomy for Adenomyosis Gargiulo AR,1 Istre O,2 Divya S,1 Srouji SS.1 1Center for Infertility and Reproductive Surgery, Brigham and Women’s Hospital/Harvard Medical School, Boston, Massachusetts; 2Center for Minimally Invasive Gynecologic Surgery, Brigham and Women’s Hospital/Harvard Medical School, Boston, Massachusetts This video describes our technique of robot-assisted laparoscopic trachelectomy in a case of symptomatic adenomyosis of the cervical stump in a patient with prior supracervical hysterectomy. Robot-assisted laparoscopic trachelectomy is a safe and simple procedure that should be part of the armamentarium of the gynecologist at a time when the supracervical hysterectomy is gaining popularity.
613 Robotic Applications in Benign Adnexal Pathology Gargiulo AR, Shah D, Srouji SS. Center for Infertility and Reproductive Surgery, Brigham and Women’s Hospital/Harvard Medical School, Boston, Massachusetts This video illustrates our recent surgical experience with two separate cases of benign tumors of the adnexa. A 22 year old nulliparous woman was referred to us for a presumably benign solid tumor of the infundibulum. We performed a robot-assisted intact enucleation of the tumor with microsurgical instrumentation and complete preservation of the lumen. A 30 year old nulliparous and woman with previous laparoscopic stripping of mature teratomata was referred to us for a recurrence in the right ovary observed in preparation for an ART cycle. We performed a robot-assisted
S177
laparoscopic stripping entirely in a specimen pouch with no spill and with sparing of normal ovarian tissue and hilar vessels. In both of these cases the use of the da Vinci robot was felt to contribute distinct advantages in terms of fertility preservation over our standard laparoscopic techniques.
614 Myomectomy and Adenomyomectomy in Single Patient Using the DaVinci Robotic Green MA, DellaBadia C. OB/GYN, Drexel University College of Medicine, Philadelphia, Pennsylvania Video case presention of a 42 year-old woman with 7 cm posterior adenomyoma and 8 cm myoma on MRI. She desires to maintain her fertility and requested a myomectomy. The advantages of robotic technology are demonstrated including improved vision, articulation for meticulous movements, facilitation of dissection, enuculeation and suturing. We show the difference between excision of a myoma with discrete tissue planes and the more technically difficulty adenomyoma where the tissues planes are indistinct.
615 Robotic Sacrocolpopexy with Rectopexy for the Combined Treatment of Severe Pelvic Organ Prolapse Guan X, Zurawin RK. Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas The patient is a 70-year-old female with a previous total abdominal hysterectomy presenting with vaginal prolapse and fecal incontinence. Her rectocele protruded to the introitus with apical vaginal descent. Colorectal surgery consultation confirmed a high rectal prolapse and associated enterocele. Laparoscopic sacrocolpopexy with concomitant rectopexy treats both the rectal and vaginal prolapse, offers good functional outcome compared with open surgery and results in less postoperative pain and faster convalescence. This combined procedure entails a high level of surgical skill and knowledge of pelvic anatomy and is facilitated by the use of the robot. Robotic sacrocolpopexy with rectopexy is a feasible and safe procedure with minimal operative morbidity for the combined treatment of rectal and pelvic organ prolapse.
616 Robotic Assisted Laparoscopic Removal of the Retained Ovary Orady ME. Obstetrics, Gynecology, and Women’s Health, Henry Ford Health System, Detroit, Michigan Extensive pelvic adhesions can make removal of retained ovaries challenging. Enhanced 3-dimensional vision and increased precision and dexterity of daVinci robotic instrumentation allows for easier dissection of extensive adhesions for delineation of difficult anatomy. This video illustrates the precise dissection made possible using daVinci assistance for laparoscopic removal of retained ovaries in a 60 year old female with a previous history of multiple abdominal surgeries, including an abdominal hysterectomy performed for endometriosis. She presented with complaints of pelvic discomfort. Evaluation revealed a slowly enlarging complex 11x8x9 cm ovarian mass with normal tumor markers. Given the expectations of extensive adhesions and difficult removal of the large retained ovary intactpatient was offered a robotic assisted laparoscopic oophorectomy. This approach for efficient and safe removal of this enlarged ovary in a minimally invasive manner is outlined. The dissection of the retroperitoneal space and techniques of removing the ovary laparoscopically are discussed.