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Combined Hysteroscopic Resection and Laparoscopic Radiofrequency Ablation of Uterine Fibroids
Abstracts / Journal of Minimally Invasive Gynecology 21 (2014) S191–S227 The video demonstrates: 1) the reason for recurrent uterine prolapse after a laparoscopic hysteropexy and 2) the laparoscopic surgical technique utilized to successfully preserve the woman’s uterus with good support The patient presented with a uterine prolapse to her introitus after a failed mesh laparoscopic hysteropexy. Diagnostic laparoscopy revealed that the failure was due to inadequate mesh attachment to the uterus and cervix; the mesh was only sutured to the apex of the posterior vaginal vault. Instead we found well-attached mesh at the sacrum. Laparoscopic sacral colpohysteropexy was completed without removing the previously placed mesh and by direct attachment of the mesh to the cervix, body of the uterus and to the previously placed mesh at the sacrum. We believe failed uterine suspensions do not necessitate a hysterectomy at the time of a second suspension surgery. The treating surgeon should consider the reasons for failure and treat the etiology accordingly.
709 Parasitic Myomas after Laparoscopic Myomectomy and Tissue Retrival Using Mechanical Morcellation: An Emerging Complication Munshi SA. Gynaec Endoscopy, Pulse Women’s Hospital, Ahmedabad, Gujarat, India To report the development of parasitic myomas after the use of a morcellator. Two cases of parasitic myomas over the 6-year were identified. Both were asymptomatic and picked up during fertility work up . The prevalence of this complication, considering all women with whom the electric morcellator was used (n = 1680) was 0.11% SUMMARY AND DISCUSSION: Laparoscopic myomectomy with the use of a morcellator is associated with an increased risk of developing of parasitic myomas. A thorough inspection and washing of the abdominopelvic cavity at the end of the surgery should be performed to prevent this rare complication. Multiple paracytic myomas identifies following previous morcellation can be very safely and effectively handelled by Laparscopic apporoach. Considering their varied location and vascular supply different dissection techniques is suggested to avoid complication and effective treatment. Morcellation in Endoscopic Bag is a useful technique to further prevent future recurrence.
710 Combined Hysteroscopic Resection and Laparoscopic Radiofrequency Ablation of Uterine Fibroids Musselman BM, DellaBadia CR, Patel N. Minimally Invasive Gynecologic Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania Laparoscopic radiofrequency ablation of uterine leiomyomas under laparoscopic ultrasound guidance, the Acessa Procedure by Halt Medical, is a new alternative to other fibroid treatments. The Acessa Procedure offers many advantages to the patient. It is a minimally invasive uterine-sparing procedure that can be done in an outpatient setting. Data has shown that patients have decreased symptom severity and menstrual bleeding, decreased uterine and fibroid volume, and increased quality of life following this procedure (Chudnoff SG et al, Obstetrics & Gynecology, May 2013 ). The procedure allows for targeted treatment of the fibroids, sparing the myometrium. By utilizing laparoscopic ultrasonography, this procedure allows for visualization and treatment of intramural and submucosal fibroids that may be hard to detect or remove via traditional laparoscopic myomectomy. Our video describes a procedure where we hysteroscopically resected a Type 0 submucosal fibroid and ablated numerous intramural and subserosal fibroids laparoscopically for a patient with menorrhagia.
S221
711 Methods to Reduce Blood Loss during Laparoscopic Myomectomy Opoku-Anane J, Gonzalez A, Moawad G, Marfori C, Robinson JK. Obstetrics and Gynecology, George Washington University, Washington, District of Columbia Myomectomy can be associated with life-threatening bleeding and a prolonged postoperative stay. Knowledge of interventions to reduce bleeding is essential to prevent mobility associated with the procedure. Several evidence based methods have been associated with decreased hemorrhage during myomectomy including intramyometrial vasopressin, pericervical tourniquets, misoprostol, bupivicane plus epinephrine, and compounds that alter the coagulation cascade. However most of these methods have been designed and used for open abdominal rather than laparoscopic myomectomy. This video demonstrates laparoscopic techniques to decrease blood loss during myomectomy including laparoscopic bulldogs, pericervical tourniquets, tourniquets around pedunculated fibroids, and vasopressin. 712 Extraction Techniques for Large Uteri After Robotic or Laparoscopic Hysterectomy Orady ME. Obstetrics, Gynecology, and Women’s Health, Cleveland Clinic, Cleveland, Ohio After the performance of robotic or laparoscopic hysterectomy, extraction of large uteri must be performed in order to remove the uterus while preserving the benefit of small incisions. Mechanical morcellation is utilized to cut the uterus into strips allowing its removal through 15-20 mm incisions. However, as often fragments are spread in the peritoneal cavity, concern about recurrence with peritoneal leimyomatosis or upstaging of occult malignancies, as well as other limitations has lead many gynecologists to search for other alternatives for uterine extraction including vaginal or mini-lap morcellation techniques. This vide will review different methods of uterine extraction including indications and limitations. Equipment and tools needed as well as an efficient and safe technique for each method will be described. 713 Ribbon Coring Technique: An Alternative Approach to Morcellation Patel N, Delvadia D, Musselman B. Department of Obstetrics and Gynecology, Drexel University College of Medicine, Philadelphia, Pennsylvania Tissue morcellation has been performed laparoscopically since the 1970’s with the FDA first approving a mechanical morcellator in 1995. As laparoscopy has evolved so have mechanical morcellators. But recent concerns have garnered close scrutiny of open power morcellation. As a result, the FDA has recommended the cessation of all power morcellation. Additionally, many medical centers have placed a moratorium on power morcellation. This ban has led to many surgeons considering alternate methods of tissue extraction, such as laparotomy. As laparoscopic technology furiously races to develop newer alternatives to power morcellators, there is an interim need for minimally invasive methods of morcellation. One technique is presented in this video. With a small incision, the specimen can be spirally cut into a long ribbon until it is easily removed from the abdomen. This ‘‘ribbon coring technique’’ can be learned quickly and performed with minimal risk to the patient. 714 Laparoscopic Resection of Cornual Pregnancy – Techniques to Minimize Blood Loss Sandoval-Herrera C, Srinivasan S. Obstetrics and Gynecology, Mount Sinai Hospital, Chicago, Illinois
709 Parasitic Myomas after Laparoscopic Myomectomy and Tissue Retrival Using Mechanical Morcellation: An Emerging Complication Munshi SA. Gynaec Endoscopy, Pulse Women’s Hospital, Ahmedabad, Gujarat, India To report the development of parasitic myomas after the use of a morcellator. Two cases of parasitic myomas over the 6-year were identified. Both were asymptomatic and picked up during fertility work up . The prevalence of this complication, considering all women with whom the electric morcellator was used (n = 1680) was 0.11% SUMMARY AND DISCUSSION: Laparoscopic myomectomy with the use of a morcellator is associated with an increased risk of developing of parasitic myomas. A thorough inspection and washing of the abdominopelvic cavity at the end of the surgery should be performed to prevent this rare complication. Multiple paracytic myomas identifies following previous morcellation can be very safely and effectively handelled by Laparscopic apporoach. Considering their varied location and vascular supply different dissection techniques is suggested to avoid complication and effective treatment. Morcellation in Endoscopic Bag is a useful technique to further prevent future recurrence.
710 Combined Hysteroscopic Resection and Laparoscopic Radiofrequency Ablation of Uterine Fibroids Musselman BM, DellaBadia CR, Patel N. Minimally Invasive Gynecologic Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania Laparoscopic radiofrequency ablation of uterine leiomyomas under laparoscopic ultrasound guidance, the Acessa Procedure by Halt Medical, is a new alternative to other fibroid treatments. The Acessa Procedure offers many advantages to the patient. It is a minimally invasive uterine-sparing procedure that can be done in an outpatient setting. Data has shown that patients have decreased symptom severity and menstrual bleeding, decreased uterine and fibroid volume, and increased quality of life following this procedure (Chudnoff SG et al, Obstetrics & Gynecology, May 2013 ). The procedure allows for targeted treatment of the fibroids, sparing the myometrium. By utilizing laparoscopic ultrasonography, this procedure allows for visualization and treatment of intramural and submucosal fibroids that may be hard to detect or remove via traditional laparoscopic myomectomy. Our video describes a procedure where we hysteroscopically resected a Type 0 submucosal fibroid and ablated numerous intramural and subserosal fibroids laparoscopically for a patient with menorrhagia.
S221
711 Methods to Reduce Blood Loss during Laparoscopic Myomectomy Opoku-Anane J, Gonzalez A, Moawad G, Marfori C, Robinson JK. Obstetrics and Gynecology, George Washington University, Washington, District of Columbia Myomectomy can be associated with life-threatening bleeding and a prolonged postoperative stay. Knowledge of interventions to reduce bleeding is essential to prevent mobility associated with the procedure. Several evidence based methods have been associated with decreased hemorrhage during myomectomy including intramyometrial vasopressin, pericervical tourniquets, misoprostol, bupivicane plus epinephrine, and compounds that alter the coagulation cascade. However most of these methods have been designed and used for open abdominal rather than laparoscopic myomectomy. This video demonstrates laparoscopic techniques to decrease blood loss during myomectomy including laparoscopic bulldogs, pericervical tourniquets, tourniquets around pedunculated fibroids, and vasopressin. 712 Extraction Techniques for Large Uteri After Robotic or Laparoscopic Hysterectomy Orady ME. Obstetrics, Gynecology, and Women’s Health, Cleveland Clinic, Cleveland, Ohio After the performance of robotic or laparoscopic hysterectomy, extraction of large uteri must be performed in order to remove the uterus while preserving the benefit of small incisions. Mechanical morcellation is utilized to cut the uterus into strips allowing its removal through 15-20 mm incisions. However, as often fragments are spread in the peritoneal cavity, concern about recurrence with peritoneal leimyomatosis or upstaging of occult malignancies, as well as other limitations has lead many gynecologists to search for other alternatives for uterine extraction including vaginal or mini-lap morcellation techniques. This vide will review different methods of uterine extraction including indications and limitations. Equipment and tools needed as well as an efficient and safe technique for each method will be described. 713 Ribbon Coring Technique: An Alternative Approach to Morcellation Patel N, Delvadia D, Musselman B. Department of Obstetrics and Gynecology, Drexel University College of Medicine, Philadelphia, Pennsylvania Tissue morcellation has been performed laparoscopically since the 1970’s with the FDA first approving a mechanical morcellator in 1995. As laparoscopy has evolved so have mechanical morcellators. But recent concerns have garnered close scrutiny of open power morcellation. As a result, the FDA has recommended the cessation of all power morcellation. Additionally, many medical centers have placed a moratorium on power morcellation. This ban has led to many surgeons considering alternate methods of tissue extraction, such as laparotomy. As laparoscopic technology furiously races to develop newer alternatives to power morcellators, there is an interim need for minimally invasive methods of morcellation. One technique is presented in this video. With a small incision, the specimen can be spirally cut into a long ribbon until it is easily removed from the abdomen. This ‘‘ribbon coring technique’’ can be learned quickly and performed with minimal risk to the patient. 714 Laparoscopic Resection of Cornual Pregnancy – Techniques to Minimize Blood Loss Sandoval-Herrera C, Srinivasan S. Obstetrics and Gynecology, Mount Sinai Hospital, Chicago, Illinois