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Fundamentals of Trocar Placement in Laparoscopic Gynecologic Surgery
Abstracts / Journal of Minimally Invasive Gynecology 23 (2016) S1–S252 apical pelvic organ prolapse. This video shares some of our techniques for improving efficiency which leads to savings in time spent in the OR, reproducibility and reduced cost. 313
Video Session 5 - Urogyn/Pelvic Floor Disorders/Vaginal Surgery (2:15 PM - 3:15 PM) 2:47 PM – GROUP B
Robotic-Assisted Single Site High Utero-Sacral Ligament Suspension: A Novel Minimally Invasive Alternative for the Repair of Symptomatic Pelvic Organ Prolapse Ricardo M,1 Wagner JR.2 1Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, New York; 2Obstetrics and Gynecology, Huntington Hospital/Northwell Health, Huntington, New York The purpose of this video is to demonstrate an alternative technique for the treatment of symptomatic pelvic organ prolapse. Without having to use mesh, it is possible to perform a high utero-sacral ligament suspension, as long as the ligaments are intact, in a novel minimally invasive approach using robotic-assisted single site modality. A supracervical hysterectomy, although not necessary for this procedure, was performed to allow better mobilization of the cervix, to strengthen and improve the approximation between the utero-sacral ligaments and the cervix. Also, the patient had a strong desire for cervical retention. RASS-high utero-sacral ligament suspension is a safe and effective procedure for symptomatic pelvic organ prolapse. 314
Video Session 5 - Urogyn/Pelvic Floor Disorders/Vaginal Surgery (2:15 PM - 3:15 PM)
S123
prior C-section is not a contraindication to total vaginal hysterectomy (TVH), and there are well documented advantages to the vaginal route, including less risk of ureteral injury, cuff dehiscence and less cost. However anterior cul de sac adhesions of bladder and/or uterus to the anterior abdominal wall make the laparoscopic route safer. We describe a simple way to assess for uterine and anterior cul de sac adhesions using saline infused through the posterior colpotomy incision via a foley catheter and transvaginal ultrasound to assess for adhesions to determine if TVH is feasible or whether laparoscopic hysterectomy is safer. 316
Video Session 5 - Urogyn/Pelvic Floor Disorders/Vaginal Surgery (2:15 PM - 3:15 PM) 3:08 PM – GROUP B
Latzko Operation: A Simple and Effective Minimally Invasive Surgery for the Early Correction of PostHysterectomy Vesicovaginal Fistula Moon H, Kim SG, Park GS, Koo J. Center for Minimally Invasive Surgery, Department of Obstetrics and Gynecology, Good Moonhwa Hospital, Busan, Republic of Korea The reported incidence of vesicovaginal fistula following hysterectomy is about 0.2%. Standard management of vesicovaginal fistula requires a 3-6 month interval from injury to repair to ensure complete resolution of necrosis and inflammation. However, some have advocated early closure of fistulas with good results. In 1942, Latzko developed a technique whereby post-hysterectomy vesicovaginal fistulas were treated through a purely vaginal approach, of which result was excellent. It has the advantages of a short operation time, minimal blood loss, and low postoperative morbidity while being simple and minimally invasive. We would like to present a case of early intervention of vesicovaginal fistula at 1 month after hysterectomy through the simple and effective Latzko procedure.
2:54 PM – GROUP B Robotic-Assisted Excision of a Urachal Diverticulum Frazzini Padilla PM, Kwon SY. Obstetrics and Gynecology, Rush University Medical Center, Chicago, Illinois Purpose: To demonstrate a robotic-assisted laparoscopic excision of a urachal diverticulum with concurrent use of cystoscopy to ensure complete excision of the urachal remnant. Patient: A 60 year old gravida 0 female presented with a long history of multiple recurrent culture proven urinary tract infections. A urachal diverticulum was suspected on diagnostic cystoscopy and confirmed with CT scan. Patient was counseled on management options and elected to undergo robotic-assisted excision of the diverticulum. Method: Laparoscopic robotic-assisted excision of the diverticulum was performed with concurrent cystoscopy to ensure that performance of a partial cystectomy resulted in complete excision of the urachal remnant. Conclusion: The patient recovered well with complete resolution of her symptoms. Robotic-assisted excision of a urachal diverticulum with concurrent cystoscopy is a safe, efficient and effective procedure for complete excision of the symptomatic remnant. 315
Video Session 5 - Urogyn/Pelvic Floor Disorders/Vaginal Surgery (2:15 PM - 3:15 PM) 3:01 PM – GROUP B
317
Video Session 6 - Basic Science/Research/Education (2:15 PM - 3:15 PM) 2:15 PM – GROUP A
Avascular Planes of the Pelvis Louie M,1 Siedhoff MT.2 1Ob/Gyn, University of North Carolina, Chapel Hill, North Carolina 2 Cedars-Sinai Medical Center, Los Angeles, California The avascular planes of the pelvis are potential spaces that are generally devoid of blood vessels and nerves. Knowledge of the avascular planes of the pelvis allows for safe and efficient gynecologic surgery. Access to the avascular pelvic spaces optimizes visualization by maximizing exposure and hemostasis while avoiding injury to nearby viscera, vessels, and nerves. The objectives of our video are to review the structural anatomy and landmarks in six key avascular planes of the pelvis: the pararectal space, the paravesical space, the retropubic space or space of Retizus, the vesicovaginal space, the rectovaginal space, and the presacral or retrorectal space. For each space, we discuss techniques for access and surgical dissection and review relevant safety concerns. 318
Video Session 6 - Basic Science/Research/Education (2:15 PM - 3:15 PM) 2:22 PM – GROUP A
Evaluation for Anterior C-Section Adhesions Using Vaginal Ultrasound to Determine Hysterectomy Route Kammire LD. Obstetrics and Gynecology, Wake Forest School of Medicine, Winston-Salem, North Carolina
Fundamentals of Trocar Placement in Laparoscopic Gynecologic Surgery Pacis MM, Li H, Harkins GJ. Division of Minimally Invasive Gyn Surgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
Currently almost 1/3 of all women in the United States will be delivered by C-section, and many of these women may eventually need hysterectomy. A
Trocar placement is a basic yet essential skill required for the effective performance of endoscopic surgery. Proper trocar
S124
Abstracts / Journal of Minimally Invasive Gynecology 23 (2016) S1–S252
placement can have a large impact on the technical performance of laparoscopic procedures. Additionally, improper trocar insertion can result in serious, and even life-threatening complications. Our video entitled Fundamentals of Trocar Placement in Laparoscopic Gynecologic Surgery is an educational tool designed for medical students and residents. Surgeons in training will be oriented to and have a general understanding of the central concepts of trocar placement including anatomic landmarks, safety considerations, and placement of primary and secondary trocars in laparoscopic gynecologic surgery. 319
Video Session 6 - Basic Science/Research/Education (2:15 PM - 3:15 PM) 2:29 PM – GROUP A
Teaching Laparoscopic Hysterectomy: Basic Anatomy and Surgical Steps Johnson CM,1 Gujral H,2 Wright KN.2 1Obstetrics and Gynecology, Tufts Medical Center, Boston, Massachusetts; 2Minimally Invasive Gynecologic Surgery, Lahey Hospital and Medical Center, Burlington, Massachusetts This video reviews basic pelvic anatomy, the steps of a laparoscopic hysterectomy, and some potential sites for injury. It was designed as part of a larger video curriculum for gynecologic surgery and can be used as teaching adjunct for medical students and junior residents. Our objective was to provide background for and reinforcement of intraoperative teaching. This allows learners to individualize needs for repetition, strengthen knowledge outside of the operating room, and focus on more advanced skills during live operative time.
320
Video Session 6 - Basic Science/Research/Education (2:15 PM - 3:15 PM) 2:36 PM – GROUP A
Laparoscopic Management of Mullerian Remnants Tanchoco MLC, Aguilar AS. Obstetrics and Gynecology Section of Reproductive Endocrinology and Infertility, University of the Philippines - Philippine General Hospital, Manila, Philippines This is a 12-year old child with ambiguous genitalia. Testosterone, DHEAS and estradiol levels. The 17-OHP and FSH levels were elevated. The AMH, LH, FT4, TSH and IGF-1 levels were normal. Pelvic ultrasound showed infantile uterus with thin endometrium and small ovaries. X-ray of left wrist exhibited a bone age between 12 to 14 years. Karyotyping showed a mosaic karyotype. One cell line showed monosomy X. A second cell line showed a normal karyotype. A multidisciplinary team met and the agreed procedure was preoperative diagnostic cystourethroscopy and genitoscopy, total laparoscopic hysterectomy with bilateral gonadectomy and first stage repair of hypospadia. An infantile uterus and bilateral tubular structures connecting the gonads were noted. Examination revealed a uterus with atrophic endometrium and prostatic tissue within muscle. Biopsy of the right gonad showed calcified testis, immature, with epididymis and vas deferens while the left gonad resembled oviduct tissue with immature testis.
321
Video Session 6 - Basic Science/Research/Education (2:15 PM - 3:15 PM) 2:47 PM – GROUP B
Colpotomy: A Novel Visible Landmark for Laparoscopic Hysterectomy Education Huang F, Gisseman J, Guan X. Baylor College of Medicine, Houston, Texas Study Objective: To show and describe a modified laparoscopic hysterectomy technique we use to improve junior surgeons’ (residents, fellows) education. Interventions: Total laparoscopic hysterectomy was modified by performing colpotomy prior to uterine artery cauterization and cardinal ligament transection. Patient: A 30-year-old woman with a history of endometriosis and suspected adenomyosis presented with chronic pelvic pain for 5 years and requested laparoscopic hysterectomy. Results: Performing colpotomy before uterine artery cauterization and cardinal ligament transection will help build up junior surgeons’ confidence and reduce surgical complications. 322
Video Session 6 - Basic Science/Research/Education (2:15 PM - 3:15 PM) 2:54 PM – GROUP B
Suture Technique Tips Demo Using K-Box: A Novel, Real Simulating, Ergonomic and Non-Expensive Training Box That Everyone Can Own Kuo H-H. Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linko, Taoyuan, Taiwan The learning curve of laparoscopic training is steep and includes skills such as hand-eye or hand-hand coordination, depth perception and ambidexterity. Current commercially available mechanical simulators shares some drawbacks including the high price (> 1000 USD), non-flexible image systems (expensive cam and repair fees), unreal ergonomics (operating in front of the operating platform), unreal surgical depth (too shallow to simplify the real operation) and expensive or non-repeatable platform. The K-Box not only overcome the drawbacks above but offers the advantages such as the build-in light system, multi-access port sites (assistant, suprapubic, Lee-Huang point), practice of single-site surgery and convenience to record the training processes. The cost is about 200 USD and could be even low in the future. Everybody should own one and practice makes perfect. 323
Video Session 6 - Basic Science/Research/Education (2:15 PM - 3:15 PM) 3:01 PM – GROUP B
The Curious Incident of the Parasitic Adnexa Nassie DI,1 Meshulam M,1 Gingold A,1 Maman M,1 Peled Y,1 Krissi H,1 Aviram A,2 Goldchmit C.1 1 Obstetrics and Gynecology, Helen Schneider Hospital for Women, Rabin Medical Center, Petach-Tikva, IL, Israel; 2Lis Maternity and Women’s Hospital, Sourasky Medical Center, Tel-Aviv, IL, Israel A 32 years old nulligravida presented to the ER three days after embryo transfer with lower abdominal pain. She had no history severe abdominal pain feats or abdominal surgery. She underwent IVF treatments due to unexplained infertility, and oocytes were retrieved from both ovaries.
Video Session 5 - Urogyn/Pelvic Floor Disorders/Vaginal Surgery (2:15 PM - 3:15 PM) 2:47 PM – GROUP B
Robotic-Assisted Single Site High Utero-Sacral Ligament Suspension: A Novel Minimally Invasive Alternative for the Repair of Symptomatic Pelvic Organ Prolapse Ricardo M,1 Wagner JR.2 1Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, New York; 2Obstetrics and Gynecology, Huntington Hospital/Northwell Health, Huntington, New York The purpose of this video is to demonstrate an alternative technique for the treatment of symptomatic pelvic organ prolapse. Without having to use mesh, it is possible to perform a high utero-sacral ligament suspension, as long as the ligaments are intact, in a novel minimally invasive approach using robotic-assisted single site modality. A supracervical hysterectomy, although not necessary for this procedure, was performed to allow better mobilization of the cervix, to strengthen and improve the approximation between the utero-sacral ligaments and the cervix. Also, the patient had a strong desire for cervical retention. RASS-high utero-sacral ligament suspension is a safe and effective procedure for symptomatic pelvic organ prolapse. 314
Video Session 5 - Urogyn/Pelvic Floor Disorders/Vaginal Surgery (2:15 PM - 3:15 PM)
S123
prior C-section is not a contraindication to total vaginal hysterectomy (TVH), and there are well documented advantages to the vaginal route, including less risk of ureteral injury, cuff dehiscence and less cost. However anterior cul de sac adhesions of bladder and/or uterus to the anterior abdominal wall make the laparoscopic route safer. We describe a simple way to assess for uterine and anterior cul de sac adhesions using saline infused through the posterior colpotomy incision via a foley catheter and transvaginal ultrasound to assess for adhesions to determine if TVH is feasible or whether laparoscopic hysterectomy is safer. 316
Video Session 5 - Urogyn/Pelvic Floor Disorders/Vaginal Surgery (2:15 PM - 3:15 PM) 3:08 PM – GROUP B
Latzko Operation: A Simple and Effective Minimally Invasive Surgery for the Early Correction of PostHysterectomy Vesicovaginal Fistula Moon H, Kim SG, Park GS, Koo J. Center for Minimally Invasive Surgery, Department of Obstetrics and Gynecology, Good Moonhwa Hospital, Busan, Republic of Korea The reported incidence of vesicovaginal fistula following hysterectomy is about 0.2%. Standard management of vesicovaginal fistula requires a 3-6 month interval from injury to repair to ensure complete resolution of necrosis and inflammation. However, some have advocated early closure of fistulas with good results. In 1942, Latzko developed a technique whereby post-hysterectomy vesicovaginal fistulas were treated through a purely vaginal approach, of which result was excellent. It has the advantages of a short operation time, minimal blood loss, and low postoperative morbidity while being simple and minimally invasive. We would like to present a case of early intervention of vesicovaginal fistula at 1 month after hysterectomy through the simple and effective Latzko procedure.
2:54 PM – GROUP B Robotic-Assisted Excision of a Urachal Diverticulum Frazzini Padilla PM, Kwon SY. Obstetrics and Gynecology, Rush University Medical Center, Chicago, Illinois Purpose: To demonstrate a robotic-assisted laparoscopic excision of a urachal diverticulum with concurrent use of cystoscopy to ensure complete excision of the urachal remnant. Patient: A 60 year old gravida 0 female presented with a long history of multiple recurrent culture proven urinary tract infections. A urachal diverticulum was suspected on diagnostic cystoscopy and confirmed with CT scan. Patient was counseled on management options and elected to undergo robotic-assisted excision of the diverticulum. Method: Laparoscopic robotic-assisted excision of the diverticulum was performed with concurrent cystoscopy to ensure that performance of a partial cystectomy resulted in complete excision of the urachal remnant. Conclusion: The patient recovered well with complete resolution of her symptoms. Robotic-assisted excision of a urachal diverticulum with concurrent cystoscopy is a safe, efficient and effective procedure for complete excision of the symptomatic remnant. 315
Video Session 5 - Urogyn/Pelvic Floor Disorders/Vaginal Surgery (2:15 PM - 3:15 PM) 3:01 PM – GROUP B
317
Video Session 6 - Basic Science/Research/Education (2:15 PM - 3:15 PM) 2:15 PM – GROUP A
Avascular Planes of the Pelvis Louie M,1 Siedhoff MT.2 1Ob/Gyn, University of North Carolina, Chapel Hill, North Carolina 2 Cedars-Sinai Medical Center, Los Angeles, California The avascular planes of the pelvis are potential spaces that are generally devoid of blood vessels and nerves. Knowledge of the avascular planes of the pelvis allows for safe and efficient gynecologic surgery. Access to the avascular pelvic spaces optimizes visualization by maximizing exposure and hemostasis while avoiding injury to nearby viscera, vessels, and nerves. The objectives of our video are to review the structural anatomy and landmarks in six key avascular planes of the pelvis: the pararectal space, the paravesical space, the retropubic space or space of Retizus, the vesicovaginal space, the rectovaginal space, and the presacral or retrorectal space. For each space, we discuss techniques for access and surgical dissection and review relevant safety concerns. 318
Video Session 6 - Basic Science/Research/Education (2:15 PM - 3:15 PM) 2:22 PM – GROUP A
Evaluation for Anterior C-Section Adhesions Using Vaginal Ultrasound to Determine Hysterectomy Route Kammire LD. Obstetrics and Gynecology, Wake Forest School of Medicine, Winston-Salem, North Carolina
Fundamentals of Trocar Placement in Laparoscopic Gynecologic Surgery Pacis MM, Li H, Harkins GJ. Division of Minimally Invasive Gyn Surgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
Currently almost 1/3 of all women in the United States will be delivered by C-section, and many of these women may eventually need hysterectomy. A
Trocar placement is a basic yet essential skill required for the effective performance of endoscopic surgery. Proper trocar
S124
Abstracts / Journal of Minimally Invasive Gynecology 23 (2016) S1–S252
placement can have a large impact on the technical performance of laparoscopic procedures. Additionally, improper trocar insertion can result in serious, and even life-threatening complications. Our video entitled Fundamentals of Trocar Placement in Laparoscopic Gynecologic Surgery is an educational tool designed for medical students and residents. Surgeons in training will be oriented to and have a general understanding of the central concepts of trocar placement including anatomic landmarks, safety considerations, and placement of primary and secondary trocars in laparoscopic gynecologic surgery. 319
Video Session 6 - Basic Science/Research/Education (2:15 PM - 3:15 PM) 2:29 PM – GROUP A
Teaching Laparoscopic Hysterectomy: Basic Anatomy and Surgical Steps Johnson CM,1 Gujral H,2 Wright KN.2 1Obstetrics and Gynecology, Tufts Medical Center, Boston, Massachusetts; 2Minimally Invasive Gynecologic Surgery, Lahey Hospital and Medical Center, Burlington, Massachusetts This video reviews basic pelvic anatomy, the steps of a laparoscopic hysterectomy, and some potential sites for injury. It was designed as part of a larger video curriculum for gynecologic surgery and can be used as teaching adjunct for medical students and junior residents. Our objective was to provide background for and reinforcement of intraoperative teaching. This allows learners to individualize needs for repetition, strengthen knowledge outside of the operating room, and focus on more advanced skills during live operative time.
320
Video Session 6 - Basic Science/Research/Education (2:15 PM - 3:15 PM) 2:36 PM – GROUP A
Laparoscopic Management of Mullerian Remnants Tanchoco MLC, Aguilar AS. Obstetrics and Gynecology Section of Reproductive Endocrinology and Infertility, University of the Philippines - Philippine General Hospital, Manila, Philippines This is a 12-year old child with ambiguous genitalia. Testosterone, DHEAS and estradiol levels. The 17-OHP and FSH levels were elevated. The AMH, LH, FT4, TSH and IGF-1 levels were normal. Pelvic ultrasound showed infantile uterus with thin endometrium and small ovaries. X-ray of left wrist exhibited a bone age between 12 to 14 years. Karyotyping showed a mosaic karyotype. One cell line showed monosomy X. A second cell line showed a normal karyotype. A multidisciplinary team met and the agreed procedure was preoperative diagnostic cystourethroscopy and genitoscopy, total laparoscopic hysterectomy with bilateral gonadectomy and first stage repair of hypospadia. An infantile uterus and bilateral tubular structures connecting the gonads were noted. Examination revealed a uterus with atrophic endometrium and prostatic tissue within muscle. Biopsy of the right gonad showed calcified testis, immature, with epididymis and vas deferens while the left gonad resembled oviduct tissue with immature testis.
321
Video Session 6 - Basic Science/Research/Education (2:15 PM - 3:15 PM) 2:47 PM – GROUP B
Colpotomy: A Novel Visible Landmark for Laparoscopic Hysterectomy Education Huang F, Gisseman J, Guan X. Baylor College of Medicine, Houston, Texas Study Objective: To show and describe a modified laparoscopic hysterectomy technique we use to improve junior surgeons’ (residents, fellows) education. Interventions: Total laparoscopic hysterectomy was modified by performing colpotomy prior to uterine artery cauterization and cardinal ligament transection. Patient: A 30-year-old woman with a history of endometriosis and suspected adenomyosis presented with chronic pelvic pain for 5 years and requested laparoscopic hysterectomy. Results: Performing colpotomy before uterine artery cauterization and cardinal ligament transection will help build up junior surgeons’ confidence and reduce surgical complications. 322
Video Session 6 - Basic Science/Research/Education (2:15 PM - 3:15 PM) 2:54 PM – GROUP B
Suture Technique Tips Demo Using K-Box: A Novel, Real Simulating, Ergonomic and Non-Expensive Training Box That Everyone Can Own Kuo H-H. Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linko, Taoyuan, Taiwan The learning curve of laparoscopic training is steep and includes skills such as hand-eye or hand-hand coordination, depth perception and ambidexterity. Current commercially available mechanical simulators shares some drawbacks including the high price (> 1000 USD), non-flexible image systems (expensive cam and repair fees), unreal ergonomics (operating in front of the operating platform), unreal surgical depth (too shallow to simplify the real operation) and expensive or non-repeatable platform. The K-Box not only overcome the drawbacks above but offers the advantages such as the build-in light system, multi-access port sites (assistant, suprapubic, Lee-Huang point), practice of single-site surgery and convenience to record the training processes. The cost is about 200 USD and could be even low in the future. Everybody should own one and practice makes perfect. 323
Video Session 6 - Basic Science/Research/Education (2:15 PM - 3:15 PM) 3:01 PM – GROUP B
The Curious Incident of the Parasitic Adnexa Nassie DI,1 Meshulam M,1 Gingold A,1 Maman M,1 Peled Y,1 Krissi H,1 Aviram A,2 Goldchmit C.1 1 Obstetrics and Gynecology, Helen Schneider Hospital for Women, Rabin Medical Center, Petach-Tikva, IL, Israel; 2Lis Maternity and Women’s Hospital, Sourasky Medical Center, Tel-Aviv, IL, Israel A 32 years old nulligravida presented to the ER three days after embryo transfer with lower abdominal pain. She had no history severe abdominal pain feats or abdominal surgery. She underwent IVF treatments due to unexplained infertility, and oocytes were retrieved from both ovaries.