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Cystosure – A Novel Technique Making Female Cystoscopy Safer, Simpler, and Standardized
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Abstracts / Journal of Minimally Invasive Gynecology 22 (2015) S1–S253
a response to these serious concerns, researchers have developed various containment techniques. These techniques describe the technique of ‘‘in-bag or contained power morcellation’’. However, in these techniques, after placing the specimen inside the bag, the bag is pierced with a trocar to insert the power morcellator inside the bag. Therefore, bag integrity is jeopardized with these techniques. The philosophy and aim of in-bag morcellation is to perform morcellation in a space isolated from the abdominal cavity. The process of bag penetration or piercing should be eliminated to prevent any direct connection of the bag surface to the intraabdominal space. The following video demonstrates a novel technique for in-bag laparoscopic morcellation using a surgical glove without the need piercing or penetrating the bag.
gynecologic surgery. The use of a containment bag is essential to reducing this risk, however, few tissue extraction systems are FDA-approved for this purpose. We present a technique for the removal of a large fibroid using a novel, FDA-approved specimen bag, a GelPOINT mini access platform, and hand morcellation with a scalpel. The bag holds up to 6,500 mL and has a flexible Alexis ring that expands in the abdomen to facilitate specimen retrieval, and expands once exteriorized to provide selfretraction. Additionally, a plastic incision guard protects against bag or organ injury during morcellation with a scalpel. This technique is a safe, feasible and efficient means to remove large tissue specimens with an FDA-approved tissue extraction system and may be especially useful in locations where power morcellation is no longer used. 431
428 Tissue Extraction for Minimally Invasive Surgery Kondrup JD, Sylvester BA, Branning ML. Ob/Gyn, Lourdes Hospital, Binghamton, New York The year 2014 was a game changer for morcellation and minimally invasive hysterectomy. The risk of unexpectedly morcellating a sarcoma came to light after an anesthesiologist at The Brigham and Women’s Hospital in Boston underwent a Supracervical Hysterectomy and was found to have disseminated leiomyosarcoma after power morcellation. This prompted the FDA to review the technique and make recommendations concerning the use of power morcellation. The FDA estimated the risk of morcellating an occult cancer at 1 in 350. However, other studies put the risk at 1 in 1700 to 1 in 8000. Nonetheless, hospitals and insurance companies have prohibited or restricted the use of power morcellation resulting in an increase in abdominal hysterectomies, the procedure that MIGS sought to decrease. This video looks at a four extraction techniques that each surgeon might find helpful in addressing the issue of tissue extraction and in preventing tissue dissemination. Other techniques exist.
Introducing Larger Equipment: A Novel Method in Laparoscopic Surgery With Smaller Port Sites Kim S, Goodman LR, Goldberg J. Obstetrics and Gynecology, Cleveland Clinic, Cleveland, Ohio Worldwide, the number of laparoscopic surgeries is increasing. Gynecologic surgeons employ laparoscopic routes frequently and the 5-mm smaller port is often favored for various reasons such as improved cosmesis, pain, and decreased hernia risk. However, larger ports are often placed for introduction of equipment such as sutures or hemostatic agents. Here we introduce a novel technique to keep the smaller port site incision while allowing for placement of larger equipment. This method employs two established lower quadrant ports: First, an instrument is placed through one existing trocar, meeting the trocar on the opposite side, then removing this trocar on the opposite side while keeping the instrument in place; this instrument is loaded with the larger equipment which can then easily be pulled into the surgical field. This technique decreases the need for increasing incision sites while allowing for efficient and easy introduction of equipment. 432
429 Cystosure – A Novel Technique Making Female Cystoscopy Safer, Simpler, and Standardized Kohli N,1 Greenberg JA,1 Miklos JR.2 1Dept of Ob/Gyn, Brigham & Women’s Hospital, Boston, Massachusetts; 2Dept of Ob/Gyn, Northside Hospital, Atlanta, Georgia Cystoscopy is a vital part of complex gynecologic surgery to rule out urinary tract injury. Unfortunately, cystoscopy is still only performed in less than 30% of indicated cases. The current technique of rigid female cystoscopy is complicated and cumbersome. In addition, credentialing and training can be a challenge. Cystosure is a new technique which allows all clinicians to perform cystoscopy and makes the procedure safer, simpler, and more standardized. There is no learning curve and most cystoscopies can be performed in under 60 seconds. The Cystosure system consists of a disposable 4 way catheter and a reusable modified mini-cystoscope. The procedure enables multiple passes without urethral trauma or infection risk. The catheter can also be used for postop drainage. Cystosure is a valuable part of the gynecologic toolbox for advanced surgeons and has the potential to replace traditional cystoscopy. 430 Contained Hand Morcellation in a Novel FDA-Approved Bag Wright KN,1 Clark NV,2 Vogell A,1 Handal-Orefice R.3 1Gynecology, Lahey Hospital and Medical Center, Burlington, Massachusetts; 2Obstetrics and Gynecology, Tufts Medical Center, Boston, Massachusetts; 3Obstetrics and Gynecology, Boston Medical Center, Boston, Massachusetts Tissue morcellation techniques are evolving to minimize the risk of disseminating benign or malignant tissue during minimally invasive
Percutaneous Laparoscopy in Gynecology Stepp KJ. Urogynecology and Minimally Invasive Surgery, Carolinas Healthcare System, Charlotte, North Carolina With the exception of vaginal hysterectomy, every surgical approach in gynecology presents risks associated with an incision or port. Laparoendoscopic single site surgery (LESS) remains a solution to reduce port-site risks. However, even in experienced centers, some patients are not optimal candidates for LESS. Risk-reducing techniques such as conventional laparoscopic, minilap, needlescopic and percutaneous approaches are defined. We present and review video clips from a series of the world firsts gynecologic procedures using novel percutaneous instrumentation that does not require ports or trocars. The Percuvance system by Teleflex consists of a strong but thin shaft that is less than 3 mm diameter. The shaft is inserted directly through the skin similar to a Verress needle. The introducer tip is then exchanged extracorporally for conventional 5mm instrument tips. Functionality and similarity to conventional laparoscopy is illustrated using various surgical tasks common in gynecology. 433 O-Ring Self Retractor for Post Partum Tubal Ligation Gonzalez LA, Islam M, Drnec S, Jamerson S. Obstetrics and Gynecology, Sparrow Hospital, Lansing, Michigan This video abstract demonstrates the use of an O-ring retractor during the performance of a post partum tubal ligation. We briefly discuss general statistics on tubal ligations, explaining the advantages and disadvantages to using this mini-laparotomy approach. The video will then illustrate step by step instructions on how to utilize and optimize the O-ring retractor during the procedure, how to safely remove the retractor and how to close each layer of the abdominal wall. Finally, a post operative image of the 2 weeks old incision will be shown. The audience will appreciate the
Abstracts / Journal of Minimally Invasive Gynecology 22 (2015) S1–S253
a response to these serious concerns, researchers have developed various containment techniques. These techniques describe the technique of ‘‘in-bag or contained power morcellation’’. However, in these techniques, after placing the specimen inside the bag, the bag is pierced with a trocar to insert the power morcellator inside the bag. Therefore, bag integrity is jeopardized with these techniques. The philosophy and aim of in-bag morcellation is to perform morcellation in a space isolated from the abdominal cavity. The process of bag penetration or piercing should be eliminated to prevent any direct connection of the bag surface to the intraabdominal space. The following video demonstrates a novel technique for in-bag laparoscopic morcellation using a surgical glove without the need piercing or penetrating the bag.
gynecologic surgery. The use of a containment bag is essential to reducing this risk, however, few tissue extraction systems are FDA-approved for this purpose. We present a technique for the removal of a large fibroid using a novel, FDA-approved specimen bag, a GelPOINT mini access platform, and hand morcellation with a scalpel. The bag holds up to 6,500 mL and has a flexible Alexis ring that expands in the abdomen to facilitate specimen retrieval, and expands once exteriorized to provide selfretraction. Additionally, a plastic incision guard protects against bag or organ injury during morcellation with a scalpel. This technique is a safe, feasible and efficient means to remove large tissue specimens with an FDA-approved tissue extraction system and may be especially useful in locations where power morcellation is no longer used. 431
428 Tissue Extraction for Minimally Invasive Surgery Kondrup JD, Sylvester BA, Branning ML. Ob/Gyn, Lourdes Hospital, Binghamton, New York The year 2014 was a game changer for morcellation and minimally invasive hysterectomy. The risk of unexpectedly morcellating a sarcoma came to light after an anesthesiologist at The Brigham and Women’s Hospital in Boston underwent a Supracervical Hysterectomy and was found to have disseminated leiomyosarcoma after power morcellation. This prompted the FDA to review the technique and make recommendations concerning the use of power morcellation. The FDA estimated the risk of morcellating an occult cancer at 1 in 350. However, other studies put the risk at 1 in 1700 to 1 in 8000. Nonetheless, hospitals and insurance companies have prohibited or restricted the use of power morcellation resulting in an increase in abdominal hysterectomies, the procedure that MIGS sought to decrease. This video looks at a four extraction techniques that each surgeon might find helpful in addressing the issue of tissue extraction and in preventing tissue dissemination. Other techniques exist.
Introducing Larger Equipment: A Novel Method in Laparoscopic Surgery With Smaller Port Sites Kim S, Goodman LR, Goldberg J. Obstetrics and Gynecology, Cleveland Clinic, Cleveland, Ohio Worldwide, the number of laparoscopic surgeries is increasing. Gynecologic surgeons employ laparoscopic routes frequently and the 5-mm smaller port is often favored for various reasons such as improved cosmesis, pain, and decreased hernia risk. However, larger ports are often placed for introduction of equipment such as sutures or hemostatic agents. Here we introduce a novel technique to keep the smaller port site incision while allowing for placement of larger equipment. This method employs two established lower quadrant ports: First, an instrument is placed through one existing trocar, meeting the trocar on the opposite side, then removing this trocar on the opposite side while keeping the instrument in place; this instrument is loaded with the larger equipment which can then easily be pulled into the surgical field. This technique decreases the need for increasing incision sites while allowing for efficient and easy introduction of equipment. 432
429 Cystosure – A Novel Technique Making Female Cystoscopy Safer, Simpler, and Standardized Kohli N,1 Greenberg JA,1 Miklos JR.2 1Dept of Ob/Gyn, Brigham & Women’s Hospital, Boston, Massachusetts; 2Dept of Ob/Gyn, Northside Hospital, Atlanta, Georgia Cystoscopy is a vital part of complex gynecologic surgery to rule out urinary tract injury. Unfortunately, cystoscopy is still only performed in less than 30% of indicated cases. The current technique of rigid female cystoscopy is complicated and cumbersome. In addition, credentialing and training can be a challenge. Cystosure is a new technique which allows all clinicians to perform cystoscopy and makes the procedure safer, simpler, and more standardized. There is no learning curve and most cystoscopies can be performed in under 60 seconds. The Cystosure system consists of a disposable 4 way catheter and a reusable modified mini-cystoscope. The procedure enables multiple passes without urethral trauma or infection risk. The catheter can also be used for postop drainage. Cystosure is a valuable part of the gynecologic toolbox for advanced surgeons and has the potential to replace traditional cystoscopy. 430 Contained Hand Morcellation in a Novel FDA-Approved Bag Wright KN,1 Clark NV,2 Vogell A,1 Handal-Orefice R.3 1Gynecology, Lahey Hospital and Medical Center, Burlington, Massachusetts; 2Obstetrics and Gynecology, Tufts Medical Center, Boston, Massachusetts; 3Obstetrics and Gynecology, Boston Medical Center, Boston, Massachusetts Tissue morcellation techniques are evolving to minimize the risk of disseminating benign or malignant tissue during minimally invasive
Percutaneous Laparoscopy in Gynecology Stepp KJ. Urogynecology and Minimally Invasive Surgery, Carolinas Healthcare System, Charlotte, North Carolina With the exception of vaginal hysterectomy, every surgical approach in gynecology presents risks associated with an incision or port. Laparoendoscopic single site surgery (LESS) remains a solution to reduce port-site risks. However, even in experienced centers, some patients are not optimal candidates for LESS. Risk-reducing techniques such as conventional laparoscopic, minilap, needlescopic and percutaneous approaches are defined. We present and review video clips from a series of the world firsts gynecologic procedures using novel percutaneous instrumentation that does not require ports or trocars. The Percuvance system by Teleflex consists of a strong but thin shaft that is less than 3 mm diameter. The shaft is inserted directly through the skin similar to a Verress needle. The introducer tip is then exchanged extracorporally for conventional 5mm instrument tips. Functionality and similarity to conventional laparoscopy is illustrated using various surgical tasks common in gynecology. 433 O-Ring Self Retractor for Post Partum Tubal Ligation Gonzalez LA, Islam M, Drnec S, Jamerson S. Obstetrics and Gynecology, Sparrow Hospital, Lansing, Michigan This video abstract demonstrates the use of an O-ring retractor during the performance of a post partum tubal ligation. We briefly discuss general statistics on tubal ligations, explaining the advantages and disadvantages to using this mini-laparotomy approach. The video will then illustrate step by step instructions on how to utilize and optimize the O-ring retractor during the procedure, how to safely remove the retractor and how to close each layer of the abdominal wall. Finally, a post operative image of the 2 weeks old incision will be shown. The audience will appreciate the