Laparoscopic Resection of Deep Infiltrating Ureteral Endometriosis and Ureteral Reanastamosis

Abstracts / Journal of Minimally Invasive Gynecology 21 (2014) S191–S227 1. to review the utility of ultrasound in diagnosis and preoperative planning in endometriosis 2. to provide a systematic approach to ultrasound for endometriosis 3. to demonstrate through case presentations, the use of targeted ultrasound in planning for surgical treatment of deep infiltrative endometriosis Endometriosis is a heterogenous disease that may present in many different ways. It is typically diagnosed on a clinical basis and the utility of imaging in diagnosis of endometriosis has been fairly limited, mainly to look for endometriomas. Recent evidence has shown that a targeted, ‘‘tenderness guided’’ ultrasound can diagnose endometriosis with a sensitivity and specificity approximating 90%. We present two cases of deep infiltrative endometriosis where a preoperative ultrasound was central in appropriate surgical planning and excellent outcome for the patient. 679 Laparoscopic Excision of Deep Rectovaginal Endometriosis Nodule Chamsy DJ, Lee TM. Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania The laparoscopic excision of a deep rectovaginal endometriosis nodule is a challenging procedure. The location of the nodule deep in the pelvic, limits exposure and access. The concomitant obliteration of the rectovaginal space makes the dissection tedious as surgical planes are distorted by the disease. Moreover, deep involvement of the rectal wall necessitates simultaneous bowel surgery. Rather than trying to penetrate an obliterated rectovaginal space to excise the vaginal and rectal components of the nodule separately and in a piece meal fashion, we illustrate a novel surgical technique which consists of resecting the rectovaginal nodule en block: we first perform a partial vaginectomy to separate the nodule from the vaginal canal. With the nodule attached to the rectum along with is vaginal portion, we perform a bowel resection to remove the rectovaginal nodule in one piece. We subsequently repair the bowel by end to end anastomosis. 680 A New Application for Barbed Suture: Repair of Cystotomy and Enterotomy Ecker AM, Lee TTM. Department of Obstetrics and Gynecology, Magee-Womens Hospital of UPMC, Pittsburgh, Pennsylvania

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laparoscopic resection of the deep infiltrating endometriosis of the ureter causing stricture and successful laparoscopic ureteroureteral reanastamosis using the same technique our practice has been applying for the past twenty years. Although this technique requires advanced laparoscopic skills the technique allows successful end to end ureteral reanastamosis in situations that previously required more extensive procedures via laparotomy. By applying the principles of laparoscopic microsurgery including adequate mobilization of the proximal and distal ureteral segments, a tension free reanastamosis, viable ureteral segments for reanastamosis, and six interrupted sutures tied in a tension free manner a patient can expect optimal outcomes at 3 months post surgery in a minimally invasive fashion. 682 Robotic Assisted Resection of Vesicovaginal Endometriosis Nodule Mahmoud MS, Apostol R, Nezhat F. Minimally Invasive Gynecology, Saint Luke’s Roosevelt Hospital, New York, New York In this video we present a case of deep infiltrative endometriosis consistent with an endometriosis nodule in the vesicovaginal area,which is resected using the laparoscopic robotic assisted approach. The details of the technique and procedure as well as anatomical considerations are reviewed during the course of the video presentation. 683 Safe Endoscopic Laser Excision and Vaporization of Peritoneal Endometriosis Nezhat C, Balassiano E, Nezhat A, Parsa MA, Nezhat C. Obstetrics and Gynecology, Stanford University Medical Center, Palo Alto, California Video-assisted laparoscopy is being used with increasing frequency in the treatment of endometriosis. However, endometriosis of sensitive areas such as the bowel, bladder, ureter and major vessels are often excluded from surgical intervention due to risk of injury. This is detrimental to the patient, as endometriosis should be treated thoroughly wherever encountered if possible. The use of CO2 laser and hydrodissection allows for safe surgical treatment of endometriosis and has several advantages, such as precision, minimal tissue damage and risk of thermal injury to adjacent structures. This is a video presentation of safe laser excision and vaporization of peritoneal endometriosis. 684

Barbed suture has been approved by the Food and Drug Administration (FDA) since 2004. Here, we show examples where a unidirectional barbed suture was used for closure of intentional cystotomy and enterotomy after resection of endometriotic nodules. Case #1: Two-layer closure of a cystotomy after removal of a 3cm bladder nodule Case #2: Two-layer closure of an enterotomy after removal of 2cm rectal nodule Key points when using barbed suture for mucosal closures include: the use of assistive devices such as a rectal probes and ureteral stents, placement of angle sutures, and creation of a tension free closure. We have found the barbed suture to be a facile means of closing mucosal defects and have had minimal to no complications as a result. It is our opinion that the barbed suture is a useful tool to consider when closing intentional mucosal defects. 681 Laparoscopic Resection of Deep Infiltrating Ureteral Endometriosis and Ureteral Reanastamosis Hadiashar M,1 Liu LA,2 Rich SJ,1 Liu CY.1 1University of Tennessee Health Science Center College of Medicine Chattanooga, Chattanooga, Tennessee; 2Lenox Hill Hospital, New York, New York Endometriosis of the ureter although uncommon can lead to stricture with subsequent hydroureter and hydronephrosis. This video demonstrates

Laparoscopic Excision of Retroperitoneal Pelvic Mass over Right Iliac Vessels Nezhat C, Balassiano E, Nezhat A. Obstetrics and Gynecology, Stanford University Medical Center, Palo Alto, California Extragenital endometriosis represents 10-15% of all endometriosis cases and is defined as the presence of endometrial glands and stroma outside of the uterine cavity and pelvis. Pain is the most common presenting symptom (76.5%) and cyclic pain is the second (41.2%). Endometriosis occurring around large pelvic vessels has been reported to cause pain, catamenial edema and DVT. Our literature review shows two cases of extragenital endometriosis compressing the iliac vessels. We are presenting a case of a 49 year old female with history of endometriosis who presented of worsening right-sided and lower extremity pain for two months. The endometriotic lesion was confirmed with CT scan and preoperative consultation with vascular surgery was obtained due to close proximity of the lesion to the iliac vessels. The laparoscopic removal of the pelvic mass is shown in this video. 685

Poster Video: Hysteroscopy, Endometrial Ablation and Sterilization

Uterine Septum Resection Ritch JMB, Yunker AC, Anderson TL. Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee