Discoid Resection of Invasive Rectosigmoid Endometriosis

Abstracts / Journal of Minimally Invasive Gynecology 22 (2015) S1–S253 Here we present a laparoscopic modification of the Osada technique for adenomyomectomy in a 36-year-old patient with 3 pregnancy losses and no live birth. A pre-operative MRI shows an 11x9x7cm focus of adenomyosis. Haemostatic control is achieved by clamping of bilateral uterine arteries and use of vasopressin. Strategies are shown for overcoming the lack of demarcation between adenomyotic and normal tissue. The transition of this efficacious technique from open to laparoscopic was successfully accomplished.

371 Single Incision Laparoscopic Hysterectomy for Severe Endometriosis Sendag F,1 Peker N,1 Aydeniz EG,1 Akdemir A,2 Gundogan S.1 1Obstetrics and Gynecology, Acibadem University Atakent Hospital, Istanbul, Atakent, Turkey; 2Obstetrics and Gynecology, Ege University School of Medicine, Izmir, Bornova, Turkey Single port laparoscopic surgery is an emerging technique and an option for improving the benefits of laparoscopic surgery. On the other hand, the single port laparoscopic surgery has some own challenges. However, despite the challenges, the current topic of interest is the use of single port laparoscopic surgery for the surgical treatment of endometriosis. Besides, initial reports have reported the feasibility of the single port laparoscopic surgery for endometriosis treatment. The use of the more advanced single access ports with single hole such as Octoport, instead of multi-channel single ports has been reported to be more feasible. Moreover, advanced optics such as flexible optics and angled optics are the potential instruments to facilitate the use of single port laparoscopic surgery. Eventually, when the advanced laparoscopic skills of the experienced surgeon merge with the aforementioned instruments, the difficulties and the challenges of single port laparoscopic surgery will come more implementable.

374 Laparoscopic Surgical Management of Juvenile Cystic Adenomyosis Rindos NB,1 Ross M,1 Carter G,2 Guido R.1 1Ob/Gyn, Magee Womens Hospital, Pittsburgh, Pennsylvania; 2Pathology, Magee Womens Hospital, Pittsburgh, Pennsylvania Juvenile cystic adenomyosis occurs in women under the age of thirty who present with severe dysmenorrhea in the setting of adenomyotic cysts at least one cm in diameter. These cysts consist of endometrial glands surrounded by myometrial tissue which often contains hemorrhagic material. The disease is not associated with diffuse uterine adenomyosis but is rather a single discrete cyst. In this video we will review the presentation of this rare condition, as well as its diagnosis and surgical management. 375 An Extra Step to Prevent Troublesome Uterine Artery Bleeding: Retroperitoneal Dissection and Ligation of the Uterine Artery at the Source Tower AM, Azodi M. Yale New Haven Health - Bridgeport Hospital, Bridgeport, Connecticut Unexpected and brisk bleeding when transecting the uterine vessels at the uterocervical junction can occur due to the multiple ascending and descending branches and accessory arteries. Attempts to control bleeding can be dangerous, as lateral spread of bipolar energy can injure the nearby ureter. A simple step to avoid this complication is retroperitoneal dissection, ureterolysis and ligation of the uterine artery at the source. This video demonstrates the complication in one case, and the preventative step in a different case. 376

372 Laparoscopic Excision of Interstitial Pregnancy Vaglio ME, Marsh C, Carey E. Obstetrics and Gynecology, University of Kansas, Kansas City, Kansas Objective: A video demonstration of laparoscopic excision of an interstitial pregnancy that was identified on a TVUS after an embryo transfer. This video demonstrates techniques to prevent excessive blood loss during the removal of the right uterine cornua. Techniques used include uterine tourniquet, placement of the a uterine manipulator under direct visualization, subserosal vasopressin, stabilization of the uterus with a v-loc while the excision was performed and a double layer closure.

373 Combined Natural Orifice Single-Site Hysterectomy Tower AM,1 Schwab C,2 Azodi M.2 1Yale New Haven Health - Bridgeport Hospital, Bridgeport, Connecticut; 2Yale New Haven Hospital, New Haven, Connecticut Single incision laparoscopy is associated with fewer scars but can be technically challenging. It also typically requires a large fascial incision. Vaginal surgery is the most minimally invasive approach to hysterectomy but does not allow for complete visualization of the peritoneal cavity. This video demonstrates a novel procedure combining these two techniques, utilizing two 5-mm abdominal trocars inserted through the umbilicus and a vaginal trocar for a surgical assistant to utilize a flexible grasper. This procedure allows for full assessment of pelvic and abdominal anatomy, decreased pain, and a desirable cosmetic outcome.

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Video Session 9 - Endometriosis (12:05 PM - 1:05 PM)

Extrinsic Ureteral Endometriosis: Tackling the Difficult Ureterolysis Ecker AM, Mansuria SM, Lee TTM. Department of Obstetrics and Gynecology, Magee-Womens Hospital of UPMC, Pittsburgh, Pennsylvania Endometriosis involving the ureter can make ureterolysis extremely challenging due to the resultant retroperitoneal fibrosis. There is risk of incomplete resection and recurrent disease as well as risk of unrecognized or delayed thermal injury to the ureter from aggressive use of electrosurgery. Here we will emphasize strategies for management of the difficult ureterolysis in three patients who presented with pelvic pain and hydronephrosis secondary to endometriosis. The key principles in performing the difficult ureterolysis include: aggressive maintenance of hemostasis to avoid staining the retroperitoneum, ligation of the uterine artery to control bleeding and complete the resection, directed blunt dissection, preservation of the peri-ureteral sheath and placement of double J stents for 4-6wks postoperatively. With these techniques, even the difficult ureterolysis can be safely completed. 377 Discoid Resection of Invasive Rectosigmoid Endometriosis Fatehchehr S,1 Macik P,2 Sinervo K.1 1Center for Endometriosis Care, Atlanta, Georgia; 2Northside Hospital, Atlanta, Georgia Introduction: Incidents of bowel Endometriosis: 3-37% [1] SYMPTOMS Painful bowel movements, Constipation, Diarrhea, Alternating constipation and diarrhea, Intestinal cramping, Nausea and/or vomiting, Abdominal pain, Rectal pain, Rectal bleeding, Appendicitis 90% the rectum or sigmoid colon are involved [2,3]

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Abstracts / Journal of Minimally Invasive Gynecology 22 (2015) S1–S253

Multidisciplinary laparoscopic treatment of extensive bowel endometriosis is standard of care [4,5] Indication for bowel resection: Invasion of more than 50% of the bowel circumference, multiple nodules, or nodules larger than 3 cm [6] COMPLICATIONS Anastomotic leakages 0.7-1.5%, Pelvic abscesses 0.3%, and rectovaginal fistulae 0.7-2.7% [7] Recurrence rate after bowel resection in 2 years: 4.7-25% [7] The cumulative pregnancy rate after bowel resection: 1 year 44%, 2 years 58%, and 3 years 73% [8]

378 Conservative Laparoscopy for the Obliterated Posterior Cul-De-Sac Lum D. Obstetrics and Gynecology, Stanford University, Stanford, California Complete obliteration of the posterior cul-de-sac in women with endometriosis can pose a challenge for the gynecologic surgeon. It is considered by most experts to be the most severe form of the disease and the most difficult to treat surgically. Surgical management of endometriosis includes conservative or definitive surgery. Conservative surgery is fertility sparing. It is perhaps more challenging than definitive surgery in the case of an obliterated cul-de-sac given the goal of debulking as much disease as possible while sparing the uterus and ovaries. In this video, we present strategies to approach the obliterated posterior culde-sac in patients desiring future fertility.

379 Two Cases of Urinary Tract Endometriosis – Two Reconstruction Method After Segmental Resection Andou M, Yamanaka A, Kodama K, Shirane A, Fukuta M. Gynecology, Kurashiki Medical Center, Kurashiki, Okayama, Japan We will describe techniques to deal with large urinary tract defects after radical excision of endometriosis. Case 1 presented with extensive bladder endometriosis near the right ureteral orifice. Case two had ureteral endometriosis. Case 1 required extensive resection of the bladder and extravesical ureteral reimplantation as reconstruction. Case 2 required a laparoscopic Boari flap and psoas hitch procedure to compensate for the extensive defect of the ureter. The Boari flap duct is created and hitched to the psoas tendon. The cut end of the ureter is spatulated and reimplanted into the flap to create a submucosal tunnel. Both patients recovered well without sequel, with no stenosis or leaks and no reflux. Reconstructive techniques are necessary when performing radical gynecologic excision and allow the appropriate surgical margin to be maintained. Our minimally invasive approach using laparoscopy can make such a radical procedure patient friendly.

rare condition, which may escape detection for years or months causing unnecessary patient pain and frustration.

381 Laparoscopic Diagnosis and Treatment of Superficial Endometriosis in a Teenage Patient Cook AS, Hopton EN. Vital Health Institute, Los Gatos, California This video demonstrates the techniques required in the identification and wide surgical excision of superficial peritoneal endometriosis in a teenage patient. An 18-year-old nulligravida female presents with a history of debilitating chronic pelvic pain (4 years since onset), dysmenorrhea and deep dyspareunia. The posterior cul de sac is found to be tender on exam, although no nodularity is detected. During nearcontact laparoscopy diffuse, superficial peritoneal endometriosis is visualized involving the bilateral perirectal and periureteral spaces. All areas of abnormal tissue are circumscribed with wide margins and excised using the Carbon 13 CO2 laser, with careful hemostasis. Histopathology confirms the presence of peritoneal endometriosis in the aforementioned areas. Adhesion barriers are used to protect the deperitonealized surfaces from post-operative adhesion formation. Following surgery, the patient’s recovery is uneventful. At a year’s follow-up, the patient reports a complete resolution of her previous symptoms and a return to a full quality of life.

382 Presentation and Management of Extra-Pelvic Endometriosis of the Abdominal Wall, Perineum and Umbilicus and Intra-Peritoneal Findings Hawkins E, Shin JH, Lopez J. Obstetrics, Gynecology & Women’s Health, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York Extra-peritoneal endometriosis is rare, but due to a high overall prevalence of endometriosis, many gynecologists encounter endometriosis in atypical locations. This video demonstrates surgical management of endometriosis in 3 cases involving the abdominal wall, perineum, and umbilicus. Abdominal wall endometriosis represents approximately 4% of endometriosis cases; primary umbilical and perineal are even less common. Since endometriosis is primarily diagnosed and managed by gynecologists, it is important to be familiar with less common forms. Correlation of extra-peritoneal and intra-peritoneal endometriosis has yet to be established. In these cases, each patient experienced both pain at the sites of extra-peritoneal disease and pelvic pain. Therefore, diagnostic laparoscopy was also performed, demonstrating concomitant intra-peritoneal endometriosis. Additionally, cystoscopic hydrodistension was performed for patients with painful bladder symptoms, revealing glomerulations suggestive of interstitial cystitis. This condition is reported to coexist with endometriosis in approximately 50 percent of patients.

380 Excision of Inguinal Endometriosis Rindos NB, Lee TTM. Ob/Gyn, Magee Womens Hospital, Pittsburgh, Pennsylvania Inguinal endometriosis is a rare condition that presents with cyclical swelling and pain. In this video we present a patient who underwent surgical excision of an inguinal endometriotic nodule. We discuss the prevalence of this rare condition which was first described 120 years ago by Dr. T.S. Cullen, but has been only infrequently described in the gynecologic literature since that time. We review the diagnosis of inguinal endometriosis which relies on both high clinical suspicion and imaging with MRI. The bulk of this video presents our surgical management and a review of the relevant anatomy. Gynecologists with advanced laparoscopic training are well suited to diagnose and treat this

383 Excision of Bladder Endometriosis Under Cystoscopic Guidance Liu L,1 Shay A,1 Kerin Orbuch I,2 Orbuch L.2 1Obstetrics and Gynecology, Lenox Hill Hospital, New York, New York; 2Mount Sinai Beth Israel, New York, New York This video demonstrates robotic-assisted laparoscopic excision of a partialthickness endometriotic nodule of the dome of the bladder under cystoscopic guidance. A 28-year-old nulligravida female presents with a history of severe pelvic pain, nocturia, frequency, cyclic dysuria and hematuria. During cystoscopy a nodule measuring approximately 2 cm in diameter is visualized, but did not infiltrate the bladder mucosa. At laparoscopy the nodule is circumscribed and carefully excised under