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A Standardized Approach to the Excision of Midurethral Slings
Abstracts / Journal of Minimally Invasive Gynecology 22 (2015) S51–S66
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vesicovaginal space. We successfully removed the micro-insert using a combination of fluoroscopy and laparoscopy. Conclusion: For the avid laparoscopist, intra-operative live fluoroscopy should be considered as an adjunct resource to locate any misplaced laparoscopic instruments, lost needles or migrated metallic foreign bodies not readily seen on laparoscopic survey. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS:
visualization, and subsequent dilation of the obliterated endocervical canal with the vessel dilator. Conclusion: The case presented shows how cervical stenosis and a false passage can be overcome, using a guide wire and vessel dilator, when placed under hysterscopic guidance. These tools are readily available in any operating room. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS:
Shan Shan Jiang: Nothing to disclose Quan Bui: Nothing to disclose Emma Lewinter: Nothing to disclose Tyler M. Muffly: Nothing to disclose
Allan A. Adajar: Nothing to disclose Andrew J. Rivera: Nothing to disclose Video Cafe 22
Video Cafe 20 Hysteroscopic Managment of a Double Uterine Pathology Abdelaziz A,1 Fahmi I,1 Zaghmout O,1 Joseph S,2 Abuzeid M.1 1OBGYN, Hurley Medical Center - Michigan State University, Flint, Michigan; 2IVF Michigan, Rochester, Michigan Objective: An operative video presentation showing the managment of a combined uterine pathology (septum and fibroid), which can be managed in the same setting. Description: Video presentation showing the managment of uterine septum with concomitant removal of uterine fibroid hysteroscopically. The video shows the technique used for removal of each pathology, the instruments which was used during surgery, the steps which was taken intraoperatively, and postoperative care, which was done to avoid any complications. Conclusion: Managment of a double uterine pathologyin the uterus (submucous fibroidand uterine septum) can be done safely by an experienced surgeon in the same setting sparing the patient to go for another operation and reducing the cost. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS: Ahmed Abdelaziz: Nothing to disclose Islam Fahmi: Nothing to disclose Osama Zaghmout: Nothing to disclose Salem Joseph: Nothing to disclose Mostafa Abuzeid: Nothing to disclose
Video Cafe 21 A Novel Approach to Overcoming Cervical Stenosis and False Passages Adajar AA,1 Rivera AJ.2 1Illinois Institute of Gynecology and Advanced Pelvic Surgery, Glenview, Illinois; 2Misha Media Photography, Hoffman Estates, Illinois Objective: Cervical stenosis, and inadvertant creation of a cervical wall defect, is a difficult complication to overcome. This video demonstrates an intraoperative technique to overcome cervical stenosis and creation of a false passage, using hysteroscopic hydrodilation, and vessel dilator over a guide wire. Description: Cervical stenosis, and creation of a cervical stromal tract, during cervical dilation is an infrequent but difficult intraoperative complication to overcome. Preoperative techniques to decrease the risk of this complication have been described, and has proven benefits. Once a false passage has been created, attempts to overcome this complication often results in worsening of the stromal defect, and places the patient at greater risk for perforation at the level of the cervix. This video demonstrates an intraoperative technique to overcome cervical stenosis, and creation of a false passage, using hysteroscopic hydrodilation and a vessel dilator over a guide wire. Hysteroscopic hydrodilation provides adequate distention of both the false passage and endocervical canal, allowing adequate differentiation between the two. This technique also allows proper placement of a guide wire under direct
A Technique for Vascular Control during Robotic Myomectomy Clark L,1 Menderes G,1 Azodi M.1,2 1OB/GYN, Bridgeport Hospital/Yale New Haven Health System, Bridgeport, Connecticut; 2OB/GYN, Yale University, New Haven, Connecticut Objective: The objective of this video is to describe a unique method for vascular control when performing a robotic myomectomy. Description: Myomectomy is a procedure often reserved for the treatment of symptomatic myomas in women who desire fertility preservation. While traditionally performed via laparotomy, laparoscopic and robotic-assisted myomectomy are increasing in popularity. While studies suggest a decrease in blood loss with a robotic approach, one of the limitations to myomectomy is the remains concern for significant blood loss. In this video we demonstrate a technique for optimizing vascular control during myomectomy in a Jehovah’s Witness. She was known to have a large fibroid, heavy bleeding, and anemia. She desired fertility preservation. She was interested in a myomectomy for treatment, and was counseled regarding the risk of hysterectomy in the case of heavy bleeding. In addition to injection with a dilute solution of vasopressin, we utilized vascular clips and Bulldog clamps to temporarily occlude the uterine arteries while performing the procedure. The uterine vessels were exposed at the level of the cervix in order to provide access for the clips. Additional Bulldog clamps were available to transiently place on the utero-ovarian vessels if heavy bleeding was encountered and temporary control was needed. Estimated blood was 150mL, and her post-operative hemoglobin was 9.6 from 10.3 preoperatively. The patient was discharged home the following day. Conclusion: Techniques such as temporarily occluding the uterine vessels can be utilized during robotic-assisted myomectomy to provide improved vascular control during myomectomy. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS: Lindsay Clark: Nothing to disclose Gulden Menderes: Nothing to disclose Masoud Azodi: Nothing to disclose Video Cafe 23 A Standardized Approach to the Excision of Midurethral Slings Ellington DR, Meyer IS, Parden AM, Richter HE. Division of Urogynecology and Pelvic Reconstructive Surgery, University of Alabama at Birmingham, Birmingham, Alabama Objective: The purpose of this video presentation is to illustrate a standardized surgical technique for the excision of retropubic or transobturator midurethral slings. Description: Many indications exist for the removal of retropubic and transobturator midurethral slings (MUS), including pain, vaginal mesh exposure or extrusion, urinary obstruction, and dyspareunia, to name few. For most of these indications, a standardized vaginal approach for its excision is feasible. Several key factors go into successful excision of a MUS including: clear identification of the MUS, release of the dorsal aspect of the MUS from the urethra, and careful dissection of the MUS along its course out to the inferior pubic rami. In this case, we present a
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Abstracts / Journal of Minimally Invasive Gynecology 22 (2015) S51–S66
51 year-old female who had a transobturator tape placed for stress urinary incontinence and presented 6 years later with groin and vaginal pain, dyspareunia, and persistent mixed urinary incontinence. This pain was reproducible with palpation, and she strongly desired surgical removal. Conclusion: This technique shows that a standardized technique through a U-incision provides excellent exposure and with knowledge of surrounding anatomy, a MUS excision can be completed in a safe, efficient, and effective manner. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS: David R. Ellington: Nothing to disclose Isuzu S. Meyer: Nothing to disclose Ali M. Parden: Nothing to disclose Holly E. Richter: Pevalon, Investigator, Research Grant; Pevalon, Consultant, Consultant; Kimberly Clark, Consultant, Consultant Video Cafe 24 Laparoscopic Cystectomy of Large, Bilateral Ovarian Dermoids Cooney EJ, Makai GE, Patel NR. Obstetrics and Gynecology, Christiana Care Hospital, Newark, Delaware Objective: The video describes the case and surgical management of a young female who was diagnosed with large, bilateral ovarian mature teratomas. The objectives of the video are to demonstrate the techniques used to perform a laparoscopic cystectomy. Description: The video begins with removal of the left cyst wall from the ovarian cortex. The technique of traction-countertraction is used to aid in removal. The use of electrocautery is also demonstrated. Intracorporeal knot tying is demonstrated as needed for hemostasis of the right ovary. Specimen retrieval via specimen retrieval bag is included. The liberal use of irrigation and suction is shown and was performed in order to reduce the risk of postoperative chemical peritonitis. Conclusion: This video case demonstrates that large ovarian cysts can be successfully removed laparoscopically. This approach is beneficial in that it offers a minimally invasive approach while also preserving ovarian function. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS: Elizabeth J. Cooney: Nothing to disclose Gretchen E. Makai: Nothing to disclose Nima R. Patel: Nothing to disclose Video Cafe 25 Rectovaginal Fistula Repair Fazari A, Mohammed W. Faculty of Medicine, University of Medical Science and Technology, Khartoum, Sudan Objective: To perform Rectovaginal fistula repair. Description: A 31 year old Sudanese women, she is Para two, her first delivery ended with emergency cesarean section for alive and well baby and second one was complicated by obstructed labor for more than 24 hours and delivered vaginally stillborn baby this was five years ago at far rural area in South Sudan. She presented to hospital with fecal incontinence since that time. Office examination showed damaged anal canal. Examination under anesthesia confirmed rectovaginal defect of 4 x 3 cm. The rest of the structures look normal. Investigations were done to assure medical fitness and checked by anesthetist for complicated fistula repair surgery. Through inverted U shape incision remained part of the perineal body was approach to pass through inside anal canal and expose the defect. Using sharp dissection margins of the rectal mucosa separated from posterior aspect of posterior vaginal wall making space between them. This permits good mobilization of rectal mucosa to each other without tension. Trimming of all margins for remains fibrous tissues waas done. Alignment of mucosal layers in interrupted manner using Vicryl 2/0 with gentle check for anorectal canal, then closure of anovaginal space using
Vicryl 0 with approximation of lateral torn muscles. Vaginal wall closure and perineoraphy were done in steps using suitable suture materials. Packing vagina and anal canal with xylocaine socked gauze for 24 hours and Folly’s catheter was kept for 48 hours. Postoperatively rectovaginal fistula guided protocol was followed for antibiotics, analgesia, heparinization, perineal care, nutrition, physiotherapy, and psychological support. On follow up, she regained the physiological organs and sexual function. Conclusion: Obstetric fistula is avoidable morbidity. When happened; well trained team should take over the care to bring patient back to health as this disturbs quality of life, organs, emotion and case’s sexuality. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS: Atif Fazari: no, speaker, no Wafaa Mohammed: Nothing to disclose
Video Cafe 26 Robotic Hysterectomy for a Large Myomatous Uterus Menderes G,2,1 Baltes E,2 Silasi D.1,2 1Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, West Haven, Connecticut; 2Obstetrics and Gynecology, Yale New Haven Health/ Bridgeport Hospital, Bridgeport, Connecticut Objective: In this video, we demonstrate a robotic hysterectomy for a bulky leiomyomatous uterus. The purpose of submitting this video is to illustrate alternative techniques for better exposure of pedicles in performing laparoscopic hysterectomy for large uteri. Description: Patient is a 42 year-old African American who had tried multiple medical management options in the past with no improvement in her symptoms. She was referred to our clinic for definitive surgical management. Pre-operative imaging revealed a uterus measuring 25 x 15 x 10 cm with multiple leiomyomas. The patient was taken to the operating room for robotic hysterectomy. Trocars were placed in a sunrise distribution with the camera port placed supra-umbilically. Exposure was very challenging throughout the procedure. Bilateral extensive retroperitoneal dissection had to be carried out for skeletonization of the uterine vessels and for performing ureterolysis. Retrograde hysterectomy approach was employed on the left side for securing the vascular pedicle. This allowed the surgeon to better expose the left pelvic sidewall and to complete ureteolysis in a retrograde manner. After completion of the hysterectomy, uterus was delivered into the vagina and was morcellated in a contained manner with scissors. Patient had an uneventful postoperative course. Final pathology revealed uterus weighing 2040 grams with multiple leiomyomas. Conclusion: Robotic hysterectomy can be safely and successfully completed for patients with very large uteri by employing alternative techniques for exposing pedicles and retroperitoneal dissection, in the hands of experienced laparoscopic surgeons. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS: Gulden Menderes: Nothing to disclose Emily Baltes: Nothing to disclose Dan-Arin Silasi: Nothing to disclose
Video Cafe 27 Rectal Endometriosis Resection: Repair with Barbed Suture Ecker A, Lee T. OB/GYN, Magee Womens Hospital UPMC, Pittsburgh, Pennsylvania Objective: Use of barbed suture is becoming more prevalent in minimally invasive gynecologic surgery and there is a role for its utilization in closure of bowel defects after excision of endometriotic nodules. Description: This video demonstrates two examples where a unidirectional barbed suture was used for closure of both small and large enterotomies. Several key strategies to facilitate these closures are described including:
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vesicovaginal space. We successfully removed the micro-insert using a combination of fluoroscopy and laparoscopy. Conclusion: For the avid laparoscopist, intra-operative live fluoroscopy should be considered as an adjunct resource to locate any misplaced laparoscopic instruments, lost needles or migrated metallic foreign bodies not readily seen on laparoscopic survey. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS:
visualization, and subsequent dilation of the obliterated endocervical canal with the vessel dilator. Conclusion: The case presented shows how cervical stenosis and a false passage can be overcome, using a guide wire and vessel dilator, when placed under hysterscopic guidance. These tools are readily available in any operating room. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS:
Shan Shan Jiang: Nothing to disclose Quan Bui: Nothing to disclose Emma Lewinter: Nothing to disclose Tyler M. Muffly: Nothing to disclose
Allan A. Adajar: Nothing to disclose Andrew J. Rivera: Nothing to disclose Video Cafe 22
Video Cafe 20 Hysteroscopic Managment of a Double Uterine Pathology Abdelaziz A,1 Fahmi I,1 Zaghmout O,1 Joseph S,2 Abuzeid M.1 1OBGYN, Hurley Medical Center - Michigan State University, Flint, Michigan; 2IVF Michigan, Rochester, Michigan Objective: An operative video presentation showing the managment of a combined uterine pathology (septum and fibroid), which can be managed in the same setting. Description: Video presentation showing the managment of uterine septum with concomitant removal of uterine fibroid hysteroscopically. The video shows the technique used for removal of each pathology, the instruments which was used during surgery, the steps which was taken intraoperatively, and postoperative care, which was done to avoid any complications. Conclusion: Managment of a double uterine pathologyin the uterus (submucous fibroidand uterine septum) can be done safely by an experienced surgeon in the same setting sparing the patient to go for another operation and reducing the cost. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS: Ahmed Abdelaziz: Nothing to disclose Islam Fahmi: Nothing to disclose Osama Zaghmout: Nothing to disclose Salem Joseph: Nothing to disclose Mostafa Abuzeid: Nothing to disclose
Video Cafe 21 A Novel Approach to Overcoming Cervical Stenosis and False Passages Adajar AA,1 Rivera AJ.2 1Illinois Institute of Gynecology and Advanced Pelvic Surgery, Glenview, Illinois; 2Misha Media Photography, Hoffman Estates, Illinois Objective: Cervical stenosis, and inadvertant creation of a cervical wall defect, is a difficult complication to overcome. This video demonstrates an intraoperative technique to overcome cervical stenosis and creation of a false passage, using hysteroscopic hydrodilation, and vessel dilator over a guide wire. Description: Cervical stenosis, and creation of a cervical stromal tract, during cervical dilation is an infrequent but difficult intraoperative complication to overcome. Preoperative techniques to decrease the risk of this complication have been described, and has proven benefits. Once a false passage has been created, attempts to overcome this complication often results in worsening of the stromal defect, and places the patient at greater risk for perforation at the level of the cervix. This video demonstrates an intraoperative technique to overcome cervical stenosis, and creation of a false passage, using hysteroscopic hydrodilation and a vessel dilator over a guide wire. Hysteroscopic hydrodilation provides adequate distention of both the false passage and endocervical canal, allowing adequate differentiation between the two. This technique also allows proper placement of a guide wire under direct
A Technique for Vascular Control during Robotic Myomectomy Clark L,1 Menderes G,1 Azodi M.1,2 1OB/GYN, Bridgeport Hospital/Yale New Haven Health System, Bridgeport, Connecticut; 2OB/GYN, Yale University, New Haven, Connecticut Objective: The objective of this video is to describe a unique method for vascular control when performing a robotic myomectomy. Description: Myomectomy is a procedure often reserved for the treatment of symptomatic myomas in women who desire fertility preservation. While traditionally performed via laparotomy, laparoscopic and robotic-assisted myomectomy are increasing in popularity. While studies suggest a decrease in blood loss with a robotic approach, one of the limitations to myomectomy is the remains concern for significant blood loss. In this video we demonstrate a technique for optimizing vascular control during myomectomy in a Jehovah’s Witness. She was known to have a large fibroid, heavy bleeding, and anemia. She desired fertility preservation. She was interested in a myomectomy for treatment, and was counseled regarding the risk of hysterectomy in the case of heavy bleeding. In addition to injection with a dilute solution of vasopressin, we utilized vascular clips and Bulldog clamps to temporarily occlude the uterine arteries while performing the procedure. The uterine vessels were exposed at the level of the cervix in order to provide access for the clips. Additional Bulldog clamps were available to transiently place on the utero-ovarian vessels if heavy bleeding was encountered and temporary control was needed. Estimated blood was 150mL, and her post-operative hemoglobin was 9.6 from 10.3 preoperatively. The patient was discharged home the following day. Conclusion: Techniques such as temporarily occluding the uterine vessels can be utilized during robotic-assisted myomectomy to provide improved vascular control during myomectomy. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS: Lindsay Clark: Nothing to disclose Gulden Menderes: Nothing to disclose Masoud Azodi: Nothing to disclose Video Cafe 23 A Standardized Approach to the Excision of Midurethral Slings Ellington DR, Meyer IS, Parden AM, Richter HE. Division of Urogynecology and Pelvic Reconstructive Surgery, University of Alabama at Birmingham, Birmingham, Alabama Objective: The purpose of this video presentation is to illustrate a standardized surgical technique for the excision of retropubic or transobturator midurethral slings. Description: Many indications exist for the removal of retropubic and transobturator midurethral slings (MUS), including pain, vaginal mesh exposure or extrusion, urinary obstruction, and dyspareunia, to name few. For most of these indications, a standardized vaginal approach for its excision is feasible. Several key factors go into successful excision of a MUS including: clear identification of the MUS, release of the dorsal aspect of the MUS from the urethra, and careful dissection of the MUS along its course out to the inferior pubic rami. In this case, we present a
S64
Abstracts / Journal of Minimally Invasive Gynecology 22 (2015) S51–S66
51 year-old female who had a transobturator tape placed for stress urinary incontinence and presented 6 years later with groin and vaginal pain, dyspareunia, and persistent mixed urinary incontinence. This pain was reproducible with palpation, and she strongly desired surgical removal. Conclusion: This technique shows that a standardized technique through a U-incision provides excellent exposure and with knowledge of surrounding anatomy, a MUS excision can be completed in a safe, efficient, and effective manner. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS: David R. Ellington: Nothing to disclose Isuzu S. Meyer: Nothing to disclose Ali M. Parden: Nothing to disclose Holly E. Richter: Pevalon, Investigator, Research Grant; Pevalon, Consultant, Consultant; Kimberly Clark, Consultant, Consultant Video Cafe 24 Laparoscopic Cystectomy of Large, Bilateral Ovarian Dermoids Cooney EJ, Makai GE, Patel NR. Obstetrics and Gynecology, Christiana Care Hospital, Newark, Delaware Objective: The video describes the case and surgical management of a young female who was diagnosed with large, bilateral ovarian mature teratomas. The objectives of the video are to demonstrate the techniques used to perform a laparoscopic cystectomy. Description: The video begins with removal of the left cyst wall from the ovarian cortex. The technique of traction-countertraction is used to aid in removal. The use of electrocautery is also demonstrated. Intracorporeal knot tying is demonstrated as needed for hemostasis of the right ovary. Specimen retrieval via specimen retrieval bag is included. The liberal use of irrigation and suction is shown and was performed in order to reduce the risk of postoperative chemical peritonitis. Conclusion: This video case demonstrates that large ovarian cysts can be successfully removed laparoscopically. This approach is beneficial in that it offers a minimally invasive approach while also preserving ovarian function. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS: Elizabeth J. Cooney: Nothing to disclose Gretchen E. Makai: Nothing to disclose Nima R. Patel: Nothing to disclose Video Cafe 25 Rectovaginal Fistula Repair Fazari A, Mohammed W. Faculty of Medicine, University of Medical Science and Technology, Khartoum, Sudan Objective: To perform Rectovaginal fistula repair. Description: A 31 year old Sudanese women, she is Para two, her first delivery ended with emergency cesarean section for alive and well baby and second one was complicated by obstructed labor for more than 24 hours and delivered vaginally stillborn baby this was five years ago at far rural area in South Sudan. She presented to hospital with fecal incontinence since that time. Office examination showed damaged anal canal. Examination under anesthesia confirmed rectovaginal defect of 4 x 3 cm. The rest of the structures look normal. Investigations were done to assure medical fitness and checked by anesthetist for complicated fistula repair surgery. Through inverted U shape incision remained part of the perineal body was approach to pass through inside anal canal and expose the defect. Using sharp dissection margins of the rectal mucosa separated from posterior aspect of posterior vaginal wall making space between them. This permits good mobilization of rectal mucosa to each other without tension. Trimming of all margins for remains fibrous tissues waas done. Alignment of mucosal layers in interrupted manner using Vicryl 2/0 with gentle check for anorectal canal, then closure of anovaginal space using
Vicryl 0 with approximation of lateral torn muscles. Vaginal wall closure and perineoraphy were done in steps using suitable suture materials. Packing vagina and anal canal with xylocaine socked gauze for 24 hours and Folly’s catheter was kept for 48 hours. Postoperatively rectovaginal fistula guided protocol was followed for antibiotics, analgesia, heparinization, perineal care, nutrition, physiotherapy, and psychological support. On follow up, she regained the physiological organs and sexual function. Conclusion: Obstetric fistula is avoidable morbidity. When happened; well trained team should take over the care to bring patient back to health as this disturbs quality of life, organs, emotion and case’s sexuality. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS: Atif Fazari: no, speaker, no Wafaa Mohammed: Nothing to disclose
Video Cafe 26 Robotic Hysterectomy for a Large Myomatous Uterus Menderes G,2,1 Baltes E,2 Silasi D.1,2 1Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, West Haven, Connecticut; 2Obstetrics and Gynecology, Yale New Haven Health/ Bridgeport Hospital, Bridgeport, Connecticut Objective: In this video, we demonstrate a robotic hysterectomy for a bulky leiomyomatous uterus. The purpose of submitting this video is to illustrate alternative techniques for better exposure of pedicles in performing laparoscopic hysterectomy for large uteri. Description: Patient is a 42 year-old African American who had tried multiple medical management options in the past with no improvement in her symptoms. She was referred to our clinic for definitive surgical management. Pre-operative imaging revealed a uterus measuring 25 x 15 x 10 cm with multiple leiomyomas. The patient was taken to the operating room for robotic hysterectomy. Trocars were placed in a sunrise distribution with the camera port placed supra-umbilically. Exposure was very challenging throughout the procedure. Bilateral extensive retroperitoneal dissection had to be carried out for skeletonization of the uterine vessels and for performing ureterolysis. Retrograde hysterectomy approach was employed on the left side for securing the vascular pedicle. This allowed the surgeon to better expose the left pelvic sidewall and to complete ureteolysis in a retrograde manner. After completion of the hysterectomy, uterus was delivered into the vagina and was morcellated in a contained manner with scissors. Patient had an uneventful postoperative course. Final pathology revealed uterus weighing 2040 grams with multiple leiomyomas. Conclusion: Robotic hysterectomy can be safely and successfully completed for patients with very large uteri by employing alternative techniques for exposing pedicles and retroperitoneal dissection, in the hands of experienced laparoscopic surgeons. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS: Gulden Menderes: Nothing to disclose Emily Baltes: Nothing to disclose Dan-Arin Silasi: Nothing to disclose
Video Cafe 27 Rectal Endometriosis Resection: Repair with Barbed Suture Ecker A, Lee T. OB/GYN, Magee Womens Hospital UPMC, Pittsburgh, Pennsylvania Objective: Use of barbed suture is becoming more prevalent in minimally invasive gynecologic surgery and there is a role for its utilization in closure of bowel defects after excision of endometriotic nodules. Description: This video demonstrates two examples where a unidirectional barbed suture was used for closure of both small and large enterotomies. Several key strategies to facilitate these closures are described including: