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Laparoscopic Transabdominal Cerclage
S146
Abstracts / Journal of Minimally Invasive Gynecology 22 (2015) S1–S253
496 A Technique to Divide the Adnexal Ligaments for Huge Fibroids During Total Laparoscopic Hysterectomy Kodama K, Andou M, Shirane A, Yamanaka A. Gynecology, Kurashiki Medical Center, Kurashiki, Okayama, Japan Generally, TLH is performed by first operating on the upper ligaments, followed by the lower ligaments. However, in the case of huge fibroids, the upper ligaments, uterine tubes and ovaries cannot be observed by the camera placed in the umbilicus. Firstly, we developed the retroperitoneal space via an anterior approach and identified the uterine artery and ureter. At this point, as the uterus had poor mobility due to the fibroids, we could not observe bilateral adnexa. After isolation of the cardinal ligaments, we opened up the posterior lobe of the broad ligament, divided the cardinal ligaments, and then transected the vagina. As a result, uterus became mobile. We tilted the uterine body laterally and moved the adnexal ligaments into the operative field to make it possible to divide the adnexal ligaments without additional ports. Adjustments to our surgical technique allowed us to safely perform TLH for huge fibroids. 497 10 Practical Steps in Laparoscopic Sacrohysteropexy Hengrasmee P, Lam A. Centre for Advanced Reproductive Endosurgery, St. Leonard’s, New South Wales, Australia Laparoscopic sacrohysteropexy is a surgical procedure to correct uterine prolapse by re-suspending the prolapsed uterus to the anterior longitudinal presacral ligament using a thin strip of polypropylene mesh. It can provide both level I and II De Lancy’s pelvic supports and help maintain vaginal length without compromising its caliber. The key to success is restoring the pericervical support prior to suspension by using the polypropylene mesh to wrap around the cervix. This procedure requires understanding and knowledge in pelvic anatomy and surgical skills in laparoscopic dissection in order to avoid injuries to ureters and uterine vessels. In conclusion, laparoscopic sacrohysteropexy is an effective procedure which provides strong pelvic support, low risk of recurrence and fertility preservation. However, it requires meticulous skills in laparoscopic surgery to achieve favorable outcomes. 498 Laparoscopic Transabdominal Cerclage Saad CA, Templeman C. Obstetrics and Gynecology, University of Southern California, Keck School of Medicine, Los Angeles, California This video demonstrates our institution’s first laparoscopic transabdominal cerclage placement. The patient is a 29-year-old with a history of three prior second trimester losses, two of which had a failed transvaginal cerclage placed. We used a Rumi uterine manipulator with a Koh cup to help us identify the cervico-isthmic junction. We transected the round ligaments, developed the para-vesical and vesico-uterine spaces, created broad ligament peritoneal windows bilaterally, then skeletonized the uterine vessels bilaterally. We passed 5 mm mersiline suture on a double needle bilaterally at the cervico-isthmic junction from anterior to posterior. The cerclage was secured with four knots at the posterior aspect of the uterus. Bilateral round ligaments were reconstituted with 2-0 Prolene and the bladder flap was reapproximated with 2-0 Vicryl. The patient had an uncomplicated post-operative course and is currently attempting to conceive. Post-operative transvaginal ultrasound showed the cerclage 3 cm above the external cervical os. 499 Abdominal Migration of a Tubal Occlusive Device: A Laparoscopic Retrieval Method? Tam T, Ward K, McSorley A, Garrity L. Obstetrics and Gynecology, Presence Saint Francis Hospital, Evanston, Illinois
This video demonstrates laparoscopic removal of a tubal occlusive device that has migrated into the abdomen. Over 750,000 EssureÔ devices have been placed to date. Although expulsion of a device into the uterine cavity is uncommon, abdominal migration is even more rare. Most patients with abdominal displacement of the device are asymptomatic. However, others may experience severe adverse effects necessitating surgical removal. A review of literature yields only 13 reported cases of abdominal migration. Our patient presented with persistent left lower quadrant pain following EssureÔ placement in 2011. Post-procedural imaging demonstrated only right tubal occlusion suspicious for a displaced left tubal device. The patient failed to follow-up for hysterosalpingogram and subsequently had a pregnancy. After a normal vaginal delivery, the patient continued to have chronic pelvic pain and requested removal of the migrated device. The patient had immediate pain relief after successful removal of the device. 500 Two Techniques of Vaginal Cuff Closure in Single Incision LESS Surgery Salvay H,1 Najjar H.2 1Ob/Gyn, Palo Alto Medical Foundation, Santa Cruz, California; 2Ob/Gyn, Monash University, Clayton, VIC, Australia The primary challenge of Single Incision LESS Surgery is vaginal cuff closure. The limitations posed by triangulation in Single Incision make a two handed approach difficult. We present two techniques of single handed cuff closure using the EndoStich and free handed standard needle driver to safely and efficiently close the vaginal cuff laparoscopically. 501 Ureteric Injury in Total Laparoscopic Hysterectomy Repaired by Laparoscopic Neoureterocystostomy Trivedi PH, Gandhi AC, Parekh NA. Obstetrics & Gynaecology, Total Health Care Pvt. Ltd., Mumbai, Maharashtra, India A 47-year-old Para 2 Living 2 with complaints of severe menorrhagia and dysmenorrhea due to multiple fibroids in the uterus underwent a Total Laparoscopic Hysterectomy. During the procedure of Uterine artery clipping at the origin the left ureter was injured.The injury was identified TLH was completed and a Laparoscopic Ureteroureteric anastomosis was done. However due to mispalced DJ Stent, she required another surgery wherein she underwent Laparoscopic Neoureterocystostomy successfully. The case highlights that complications can occur even by experts. The skill is in handling proper case as per experience and confidence to achieve best results. 502 Techniques for Removing Pelvic Masses Clark Donat L, Tower AM, Azodi M. Obstetrics and Gynecology, Bridgeport Hospital/Yale New Haven Health, Bridgeport, Connecticut The objective of this educational video is to describe two techniques for removing pelvic masses. One of the challenges of laparoscopic gynecologic surgery is how to remove large specimens through small incisions. In this video we describe two unique approaches. The gelPOINT Mini platform (Applied Medical, Santa Margarita) allows extension of a abdominal port site, and is optimally used for removing solid specimens, such as fibroids. The VersaStep radially expandable sleeve (Covidian, Mansfield, MA) is used to create a colopotomy insicion, which can be used for removal of large masses. The elasticity of the vagina allows the incision to stretch and accommodate large specimens. In conclusions, numerous techniques exist for specimen removal, and it is imperative that the expert surgeon is comfortable with multiple approaches, in order to select the best technique for each procedure.
Abstracts / Journal of Minimally Invasive Gynecology 22 (2015) S1–S253
496 A Technique to Divide the Adnexal Ligaments for Huge Fibroids During Total Laparoscopic Hysterectomy Kodama K, Andou M, Shirane A, Yamanaka A. Gynecology, Kurashiki Medical Center, Kurashiki, Okayama, Japan Generally, TLH is performed by first operating on the upper ligaments, followed by the lower ligaments. However, in the case of huge fibroids, the upper ligaments, uterine tubes and ovaries cannot be observed by the camera placed in the umbilicus. Firstly, we developed the retroperitoneal space via an anterior approach and identified the uterine artery and ureter. At this point, as the uterus had poor mobility due to the fibroids, we could not observe bilateral adnexa. After isolation of the cardinal ligaments, we opened up the posterior lobe of the broad ligament, divided the cardinal ligaments, and then transected the vagina. As a result, uterus became mobile. We tilted the uterine body laterally and moved the adnexal ligaments into the operative field to make it possible to divide the adnexal ligaments without additional ports. Adjustments to our surgical technique allowed us to safely perform TLH for huge fibroids. 497 10 Practical Steps in Laparoscopic Sacrohysteropexy Hengrasmee P, Lam A. Centre for Advanced Reproductive Endosurgery, St. Leonard’s, New South Wales, Australia Laparoscopic sacrohysteropexy is a surgical procedure to correct uterine prolapse by re-suspending the prolapsed uterus to the anterior longitudinal presacral ligament using a thin strip of polypropylene mesh. It can provide both level I and II De Lancy’s pelvic supports and help maintain vaginal length without compromising its caliber. The key to success is restoring the pericervical support prior to suspension by using the polypropylene mesh to wrap around the cervix. This procedure requires understanding and knowledge in pelvic anatomy and surgical skills in laparoscopic dissection in order to avoid injuries to ureters and uterine vessels. In conclusion, laparoscopic sacrohysteropexy is an effective procedure which provides strong pelvic support, low risk of recurrence and fertility preservation. However, it requires meticulous skills in laparoscopic surgery to achieve favorable outcomes. 498 Laparoscopic Transabdominal Cerclage Saad CA, Templeman C. Obstetrics and Gynecology, University of Southern California, Keck School of Medicine, Los Angeles, California This video demonstrates our institution’s first laparoscopic transabdominal cerclage placement. The patient is a 29-year-old with a history of three prior second trimester losses, two of which had a failed transvaginal cerclage placed. We used a Rumi uterine manipulator with a Koh cup to help us identify the cervico-isthmic junction. We transected the round ligaments, developed the para-vesical and vesico-uterine spaces, created broad ligament peritoneal windows bilaterally, then skeletonized the uterine vessels bilaterally. We passed 5 mm mersiline suture on a double needle bilaterally at the cervico-isthmic junction from anterior to posterior. The cerclage was secured with four knots at the posterior aspect of the uterus. Bilateral round ligaments were reconstituted with 2-0 Prolene and the bladder flap was reapproximated with 2-0 Vicryl. The patient had an uncomplicated post-operative course and is currently attempting to conceive. Post-operative transvaginal ultrasound showed the cerclage 3 cm above the external cervical os. 499 Abdominal Migration of a Tubal Occlusive Device: A Laparoscopic Retrieval Method? Tam T, Ward K, McSorley A, Garrity L. Obstetrics and Gynecology, Presence Saint Francis Hospital, Evanston, Illinois
This video demonstrates laparoscopic removal of a tubal occlusive device that has migrated into the abdomen. Over 750,000 EssureÔ devices have been placed to date. Although expulsion of a device into the uterine cavity is uncommon, abdominal migration is even more rare. Most patients with abdominal displacement of the device are asymptomatic. However, others may experience severe adverse effects necessitating surgical removal. A review of literature yields only 13 reported cases of abdominal migration. Our patient presented with persistent left lower quadrant pain following EssureÔ placement in 2011. Post-procedural imaging demonstrated only right tubal occlusion suspicious for a displaced left tubal device. The patient failed to follow-up for hysterosalpingogram and subsequently had a pregnancy. After a normal vaginal delivery, the patient continued to have chronic pelvic pain and requested removal of the migrated device. The patient had immediate pain relief after successful removal of the device. 500 Two Techniques of Vaginal Cuff Closure in Single Incision LESS Surgery Salvay H,1 Najjar H.2 1Ob/Gyn, Palo Alto Medical Foundation, Santa Cruz, California; 2Ob/Gyn, Monash University, Clayton, VIC, Australia The primary challenge of Single Incision LESS Surgery is vaginal cuff closure. The limitations posed by triangulation in Single Incision make a two handed approach difficult. We present two techniques of single handed cuff closure using the EndoStich and free handed standard needle driver to safely and efficiently close the vaginal cuff laparoscopically. 501 Ureteric Injury in Total Laparoscopic Hysterectomy Repaired by Laparoscopic Neoureterocystostomy Trivedi PH, Gandhi AC, Parekh NA. Obstetrics & Gynaecology, Total Health Care Pvt. Ltd., Mumbai, Maharashtra, India A 47-year-old Para 2 Living 2 with complaints of severe menorrhagia and dysmenorrhea due to multiple fibroids in the uterus underwent a Total Laparoscopic Hysterectomy. During the procedure of Uterine artery clipping at the origin the left ureter was injured.The injury was identified TLH was completed and a Laparoscopic Ureteroureteric anastomosis was done. However due to mispalced DJ Stent, she required another surgery wherein she underwent Laparoscopic Neoureterocystostomy successfully. The case highlights that complications can occur even by experts. The skill is in handling proper case as per experience and confidence to achieve best results. 502 Techniques for Removing Pelvic Masses Clark Donat L, Tower AM, Azodi M. Obstetrics and Gynecology, Bridgeport Hospital/Yale New Haven Health, Bridgeport, Connecticut The objective of this educational video is to describe two techniques for removing pelvic masses. One of the challenges of laparoscopic gynecologic surgery is how to remove large specimens through small incisions. In this video we describe two unique approaches. The gelPOINT Mini platform (Applied Medical, Santa Margarita) allows extension of a abdominal port site, and is optimally used for removing solid specimens, such as fibroids. The VersaStep radially expandable sleeve (Covidian, Mansfield, MA) is used to create a colopotomy insicion, which can be used for removal of large masses. The elasticity of the vagina allows the incision to stretch and accommodate large specimens. In conclusions, numerous techniques exist for specimen removal, and it is imperative that the expert surgeon is comfortable with multiple approaches, in order to select the best technique for each procedure.