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Cervical Myomectomy
Abstracts / Journal of Minimally Invasive Gynecology 20 (2013) S50–S94 The laparoscopic discoid anterior rectal wall resection with the circular stapler is an effective option for treating selected cases of the rectosigmoid endometriosis (RSGend), namely single lesions less than 3 cm. We describe the technique in this video, step by step. First of all, all endometriotic disease is removed ‘‘en bloc’’ from the pelvic sidewalls and retrocervical area. We excise the lesion in the limit of the rectal muscular wall, leaving disease only in the rectosigmoid (RSG), to be transfixed by a longitudinal 2-0 polyglycolic suture. We introduce a 33-mm circular stapler per anus, and open it inside the intestinal lumen. By pulling the sutures, we introduce the nodule inside the stapler. We close the stapler while simultaneously moving it upwards and anteriorly, to avoid stapling the RSG posterior wall, and fire the device. The mechanical anastomosis should be situated at the anterior and lateral walls of the RSG. 271
Video Session 8dLaparoscopy (2:15 PMd2:23 PM)
Two Port Surgery Using a Detachable Retracting Device for Ovarian Cysts Andou M, Kanao H, Kurotsuchi S, Takano M. Gynecology, Kurashiki Medical Center, Kurashiki-shi, Okayama-Ken, Japan Background: One goal of minimally invasive surgery is to not only the number of ports, but also the size of port sites. We will present our techniques using a detachable retracting device (Endograb). Methods: Three procedures are presented, adnexectomy, ovarian cystectomy for serous cyst and ovarian cystectomy for benign cystic teratoma. The EndoGrab is used to place tension on ligaments and other structures for transected, in extraction of the cyst and in retrieval. For extraction, we clamp the cyst wall and rotate the forceps to peel the intact wall away from the cyst. For retrieval we anchor a retrieval bag to the abdominal wall, expand it using water, and place the specimen inside. All surgical steps are performed single-handedly. Results: No procedures required conversion and all resulted in good cosmesis. Conclusion: Tools like the detachable retractor make it possible to reduce the size and number of ports in selected cases. 272
Video Session 8dLaparoscopy (2:24 PMd2:32 PM)
Vasopressin Hydrodissection for Ovarian Cysts: A Demonstration of Technique Hammons LM, King CR, Donnellan NM, Lee T. Obstetrics and Gynecology, Magee-Women’s Hospital, Pittsburgh, Pennsylvania Ovarian cysts are a common gynecologic pathology within women of all ages. Laparoscopic techniques to decrease both difficulty and morbidity of ovarian cystectomy are desirable. In 2010, a study published in the Journal of Minimally Invasive Gynecology reported a trial using vasopressin and saline injection for ovarian cystectomy, which resulted in decreased operative times and less electrocautery utilization. With both shorter operating times and less electrocautery, it can be concluded that this innovative technique decreased both difficulty and morbidity. This video demonstrates a novel technique for vasopressin hydrodissection for ovarian cystectomy. This technique can be used for simple cysts, endometrioma, hemorrhagic cysts, and terratoma. It uses readily available tools that are easily modified, and can be easily accomplished by gynecologists familiar with laparoscopic ovarian cystectomy procedures. This method has the potential to decrease the rate of cyst rupture, morbidity, and operative times, which in turn benefits both patients and surgeons. 273
Video Session 8dLaparoscopy (2:33 PMd2:41 PM)
LESS Myomectomy: Making the Transition Scheib SA. Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, Maryland
S85
This is a video to help the advanced laparoscopic surgeon make the transition to LESS myomectomy. We discuss patient selection, equipment necessary, and a demonstration of the procedure including discussion of tips and tricks to be successful.
274
Video Session 8dLaparoscopy (2:42 PMd2:45 PM)
Cervical Myomectomy Syrcle SM, Eaton JL, Milad MP. Obstetrics and Gynecology, Northwestern University, Chicago, Illinois Leiomyomas recurrent at the cervical stump after a subtotal hysterectomy are a rare event. A 51-year woman with a history of subtotal hysterectomy for fibroids presented with a 2-3 month history of pelvic pain that was worse with sexual intercourse. A pelvic ultrasound and pelvic MRI revealed a 6 cm fibroid arising from the cervical stump. She underwent an uncomplicated laparoscopic myomectomy given her symptoms. Of note, she was also counseled to undergo a trachelectomy at the time of the procedure but patient refused to have her cervix removed. Hysterectomy is considered the definitive management for fibroids but there has been recurrence noted after hysterectomy. There are only a few reported cases of fibroids recurrent at the cervical stump in the literature. Although recurrent cervical stump fibroids are rare, this case illustrates that one must consider this potential complication when performing a subtotal hysterectomy for fibroids.
275
Video Session 8dLaparoscopy (2:46 PMd2:53 PM)
Laparoscopic Management of a Cornual Ectopic Pregnancy Winner BA, Biest SW. Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, Missouri This video, aimed at advanced gynecologic surgeons, uses a single case to show a step-by-step approach to the safe laparoscopic management of a cornual ectopic pregnancy. Cornual ectopics have been traditionally managed with open surgery, given the vascular nature of the cornua and potential for significant blood loss. However, using dilute vasopressin and a circumferential tourniquet suture technique, resection of the cornua can be accomplished with minimal blood loss. This teaching case demonstrates parallel suturing using a unidirectional barbed suture, and reinforces the fact that proficiency in laparoscopic suturing is required to safely perform advanced laparoscopic procedures. The patient in this case did very well. The estimated blood loss was 100 cc’s and she was discharged home the same day.
276
Video Session 8dLaparoscopy (2:54 PMd3:02 PM)
A Novel Approach for Benign Uterine Adnexal Pathologies: Transvaginal Single-Port NOTES Ahn KH,1 Park HT,1 Song JY,1 Hong SC,1 Kim SH,1 Lee T,2 Kim T.1 1 Obstetrics and Gynecology, Korea University Medical Center, Seoul, Korea; 2Obstetrics, Gynecology and Reproductive Sciences, MageeWomens Hospital of UPMC, Pittsburgh, Pennsylvania Transvaginal natural orifice transluminal endoscopic surgery (NOTES) with pneumoperitoneum has been used in other surgical fields, but transvaginal NOTES using a single port in gynecologic procedures has not been described despite gynecologist familiarity with the vaginal approach. In this video, we introduce a novel transvaginal single-port NOTES for benign uterine adnexal diseases and show the endoscopic views for the specific surgical anatomy. Transvaginal single-port NOTES is a feasible and attractive option to treat benign uterine adnexal pathologies.
Video Session 8dLaparoscopy (2:15 PMd2:23 PM)
Two Port Surgery Using a Detachable Retracting Device for Ovarian Cysts Andou M, Kanao H, Kurotsuchi S, Takano M. Gynecology, Kurashiki Medical Center, Kurashiki-shi, Okayama-Ken, Japan Background: One goal of minimally invasive surgery is to not only the number of ports, but also the size of port sites. We will present our techniques using a detachable retracting device (Endograb). Methods: Three procedures are presented, adnexectomy, ovarian cystectomy for serous cyst and ovarian cystectomy for benign cystic teratoma. The EndoGrab is used to place tension on ligaments and other structures for transected, in extraction of the cyst and in retrieval. For extraction, we clamp the cyst wall and rotate the forceps to peel the intact wall away from the cyst. For retrieval we anchor a retrieval bag to the abdominal wall, expand it using water, and place the specimen inside. All surgical steps are performed single-handedly. Results: No procedures required conversion and all resulted in good cosmesis. Conclusion: Tools like the detachable retractor make it possible to reduce the size and number of ports in selected cases. 272
Video Session 8dLaparoscopy (2:24 PMd2:32 PM)
Vasopressin Hydrodissection for Ovarian Cysts: A Demonstration of Technique Hammons LM, King CR, Donnellan NM, Lee T. Obstetrics and Gynecology, Magee-Women’s Hospital, Pittsburgh, Pennsylvania Ovarian cysts are a common gynecologic pathology within women of all ages. Laparoscopic techniques to decrease both difficulty and morbidity of ovarian cystectomy are desirable. In 2010, a study published in the Journal of Minimally Invasive Gynecology reported a trial using vasopressin and saline injection for ovarian cystectomy, which resulted in decreased operative times and less electrocautery utilization. With both shorter operating times and less electrocautery, it can be concluded that this innovative technique decreased both difficulty and morbidity. This video demonstrates a novel technique for vasopressin hydrodissection for ovarian cystectomy. This technique can be used for simple cysts, endometrioma, hemorrhagic cysts, and terratoma. It uses readily available tools that are easily modified, and can be easily accomplished by gynecologists familiar with laparoscopic ovarian cystectomy procedures. This method has the potential to decrease the rate of cyst rupture, morbidity, and operative times, which in turn benefits both patients and surgeons. 273
Video Session 8dLaparoscopy (2:33 PMd2:41 PM)
LESS Myomectomy: Making the Transition Scheib SA. Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, Maryland
S85
This is a video to help the advanced laparoscopic surgeon make the transition to LESS myomectomy. We discuss patient selection, equipment necessary, and a demonstration of the procedure including discussion of tips and tricks to be successful.
274
Video Session 8dLaparoscopy (2:42 PMd2:45 PM)
Cervical Myomectomy Syrcle SM, Eaton JL, Milad MP. Obstetrics and Gynecology, Northwestern University, Chicago, Illinois Leiomyomas recurrent at the cervical stump after a subtotal hysterectomy are a rare event. A 51-year woman with a history of subtotal hysterectomy for fibroids presented with a 2-3 month history of pelvic pain that was worse with sexual intercourse. A pelvic ultrasound and pelvic MRI revealed a 6 cm fibroid arising from the cervical stump. She underwent an uncomplicated laparoscopic myomectomy given her symptoms. Of note, she was also counseled to undergo a trachelectomy at the time of the procedure but patient refused to have her cervix removed. Hysterectomy is considered the definitive management for fibroids but there has been recurrence noted after hysterectomy. There are only a few reported cases of fibroids recurrent at the cervical stump in the literature. Although recurrent cervical stump fibroids are rare, this case illustrates that one must consider this potential complication when performing a subtotal hysterectomy for fibroids.
275
Video Session 8dLaparoscopy (2:46 PMd2:53 PM)
Laparoscopic Management of a Cornual Ectopic Pregnancy Winner BA, Biest SW. Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, Missouri This video, aimed at advanced gynecologic surgeons, uses a single case to show a step-by-step approach to the safe laparoscopic management of a cornual ectopic pregnancy. Cornual ectopics have been traditionally managed with open surgery, given the vascular nature of the cornua and potential for significant blood loss. However, using dilute vasopressin and a circumferential tourniquet suture technique, resection of the cornua can be accomplished with minimal blood loss. This teaching case demonstrates parallel suturing using a unidirectional barbed suture, and reinforces the fact that proficiency in laparoscopic suturing is required to safely perform advanced laparoscopic procedures. The patient in this case did very well. The estimated blood loss was 100 cc’s and she was discharged home the same day.
276
Video Session 8dLaparoscopy (2:54 PMd3:02 PM)
A Novel Approach for Benign Uterine Adnexal Pathologies: Transvaginal Single-Port NOTES Ahn KH,1 Park HT,1 Song JY,1 Hong SC,1 Kim SH,1 Lee T,2 Kim T.1 1 Obstetrics and Gynecology, Korea University Medical Center, Seoul, Korea; 2Obstetrics, Gynecology and Reproductive Sciences, MageeWomens Hospital of UPMC, Pittsburgh, Pennsylvania Transvaginal natural orifice transluminal endoscopic surgery (NOTES) with pneumoperitoneum has been used in other surgical fields, but transvaginal NOTES using a single port in gynecologic procedures has not been described despite gynecologist familiarity with the vaginal approach. In this video, we introduce a novel transvaginal single-port NOTES for benign uterine adnexal diseases and show the endoscopic views for the specific surgical anatomy. Transvaginal single-port NOTES is a feasible and attractive option to treat benign uterine adnexal pathologies.