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Extrinsic Ureteral Endometriosis: Tackling the Difficult Ureterolysis
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.
S127
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]
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.
S127
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]