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Minimally Invasive Midline Surgery “M-I-M-S” Using a Novel Suturing Technique for Sacrocervicopexy
Abstracts / Journal of Minimally Invasive Gynecology 19 (2012) S36–S70
S57
Conclusion: Due to low absolute risk of complications, selective rather than universal cystoscopy at time of hysterectomy appears to be a safe and effective practice at our institution. However, the threshold to perform a cystoscopy should be low, and in cases involving low-volume surgeons and/or significant pelvic pathology cystoscopy should be performed liberally.
166
164
Uterosacral ligament uterine suspension (USUS) has been used as a means of restoring support without mesh or graft implantation. However, the anterior apical vagina is particularly susceptible to recurrent prolapse after USUS. MRI data demonstrate the uterosacral/cardinal ligament complex attaches and supports the anterior cervix and vagina. Traditional USUS, focused on the posterior apical attachments, may inadequately restore this support the anterior apical vagina. We present a modification of our laparoscopic surgical technique which involves developing the vesicouterine fold (bladder flap) over the anterior vagina. Permanent suture is then used to capture the proximal uterosacral ligament, the distal ligament at its insertion into the vagina and cervix, then traversing the cardinal ligament to capture the anterior vaginal tissue. This procedure is carried out bilaterally, reattaching both anterior and posterior apical tissue to the proximal uterosacral ligaments with a concurrent paravaginal defect repair.
Open Communications 10dHysterectomy (4:50 PM d 4:55 PM)
Operative Outcomes and Complications: Robotic Versus Abdominal Hysterectomy for Complicated Benign Cases Beilan JA,1 Boardman LA,1 Johnson TR,1 Ahmad S,2 Bigsby GE IV,2 Finkler NJ,2 Holloway RW.2 1University of Central Florida College of Medicine, Orlando, Florida; 2Florida Hospital Cancer Institute, Orlando, Florida Study Objective: To compare patient characteristics and operative outcomes among a cohort of women undergoing robotic-assisted laparoscopic hysterectomy (RALH) or abdominal hysterectomy (AH) for management of benign disease with complex pathology. Design: This retrospective cohort study compared patients undergoing RALH between May 2006 and May 2009 to patients undergoing AH between July 2005 and May 2006. Demographic data, medical history, information on operative indications, findings, and complications were collected and analyzed. Setting: This study examined a population of women presenting to the Florida Hospital Gynecology Oncology (FHGO) Center for the management of non-malignant complex gynecologic pathology (e.g., leiomyomata, endometriosis, adenomyosis, benign ovarian masses). Patients: Women were eligible for inclusion under the following conditions: no pre- or post-operative evidence of malignancy, postoperative follow-up of R 6 months, and medical record completion of R 75%. Intervention: As this study retrospectively examined the operative outcomes of robotic versus abdominal hysterectomy, there was no intervention. Measurements and Main Results: Compared to AH patients (n = 103), RALH patients (n = 245) were less likely to have significant comorbidities (e.g., diabetes) and more likely to be of normal weight. RALH patients were less likely to have uterine weights of R500g or an adnexal or pelvic mass preoperatively. Although mean operative time was longer for RALH patients (99.8 versus 59.8 minutes), RALH resulted in reduced blood loss, reduced length of stay, and fewer wound infections postoperatively. After controlling for variables significantly associated with operative time (e.g., need for additional procedures including lysis of adhesions; BMIR40 kg/m2), mean operative time remained longer for RALH patients (adjusted means, 102.9 mins versus 52.4 mins). Early case status (i.e., first 25 RALH cases for each surgeon) was also significantly associated with longer operative times for RALH patients. Conclusion: RALH is a safe and effective option for the management of patients with complex pathology, irrespective of uterine weight or patient BMI. 165
Video Session 4dUrogynecology (3:20 PM d 3:27 PM)
Removal of Symptomatic Monarc Mesh Redwine DB. Gynecology, St. Charles Medical Center, Bend, Oregon A 68 year old female awoke from a Monarc sling procedure with right buttock pain. She developed worsening pain and leg weakness. She had point tenderness anterior to the right sacrospinous process. Laparoscopic radical dissection of the right pelvic sidewall found the fibrotic area associated with vitrification of the mesh material. The fibrotic area was removed and the patient experienced some improvement in her symptoms, although she is still bothered by lingering right leg weakness and pelvic pain. Surgical mesh behavior in the body is unpredictable and can be a cause of pain.
Video Session 4dUrogynecology (3:28 PM d 3:34 PM)
Laparoscopic Native-Tissue Uterine Suspension; a Novel Modification To Enhance Anterior Support Jeppson PC, Rardin CR. Division of Urogynecology and Reconstructive Pelvic Surgery, Alpert Medical School of Brown University, Providence, Rhode Island
167
Video Session 4dUrogynecology (3:35 PM d 3:42 PM)
Microlaparoscopy in Urogynecology: LSH and Sacrocervicopexy Rosenblatt PL, Adams SR, Shapiro A. Division of Urogynecology, Mount Auburn Hospital/Harvard Medical School, Cambridge, Massachusetts Objective: To describe the technique of using 3.5 mm trocars to reduce incision size and improve cosmesis during laparoscopic supracervical hysterectomy and sacrocervicopexy. Description: A 5 mm laparoscope is placed through the umbilicus and 3.5 mm trocars are placed in the right and left lower quadrants and in the suprapubic position. A standard approach to LSH is performed using a 3 mm bipolar instrument for coagulation. A 15 mm CISH instrument is used to core the cervix and remove the endocervical canal and surrounding cervical stroma. A disposable morcellator is introduced transvaginally through the cervical defect and transcervical morcellation is performed. Following morcellation, the 16 mm cannula becomes an access port during sacrocervicopexy for insertion and removal of mesh and sutures. Conclusion: We describe the technique of using 3.5 mm trocars and a 16 mm transcervical access port to reduce incision size during laparoscopic supracervical hysterectomy and sacrocervicopexy. 168
Video Session 4dUrogynecology (3:43 PM d 3:47 PM)
Minimally Invasive Midline Surgery ‘‘M-I-M-S’’ Using a Novel Suturing Technique for Sacrocervicopexy Apostolis CA, Adelowo A, DiSciullo AJ. Division of Urogynecology, Mount Auburn Hospital, Cambrdige, Massachusetts Single port sugery enables gynecologic surgeons to perform laparoscopic surgery through a single umbilical incision thereby eliminating the need for multiple ports. Single port surgery has been used for many different procedures including salpingo-Oopherectomy, supracervical hysterectomy and ovarian cyst removal. Its utility has not been extensively tested with pelvic reconstructive procedures, such as sacrocervicopexy, due to the advanced suturing skills and tissue manipulation needed to safely perfrom these procedure. We present a video introducing the ‘‘M-I-M-S’’ method for single port suturing. The concept behind this method is to introduce instruments through the abdominal mid-line, the line alba, thereby avoiding muscle splitting trocar placement. This method uses the 2.8mm Berci fascial closure device. We will demonstate the use of this instrument to facilitate laparoscopic suturing during single port surgery.
S57
Conclusion: Due to low absolute risk of complications, selective rather than universal cystoscopy at time of hysterectomy appears to be a safe and effective practice at our institution. However, the threshold to perform a cystoscopy should be low, and in cases involving low-volume surgeons and/or significant pelvic pathology cystoscopy should be performed liberally.
166
164
Uterosacral ligament uterine suspension (USUS) has been used as a means of restoring support without mesh or graft implantation. However, the anterior apical vagina is particularly susceptible to recurrent prolapse after USUS. MRI data demonstrate the uterosacral/cardinal ligament complex attaches and supports the anterior cervix and vagina. Traditional USUS, focused on the posterior apical attachments, may inadequately restore this support the anterior apical vagina. We present a modification of our laparoscopic surgical technique which involves developing the vesicouterine fold (bladder flap) over the anterior vagina. Permanent suture is then used to capture the proximal uterosacral ligament, the distal ligament at its insertion into the vagina and cervix, then traversing the cardinal ligament to capture the anterior vaginal tissue. This procedure is carried out bilaterally, reattaching both anterior and posterior apical tissue to the proximal uterosacral ligaments with a concurrent paravaginal defect repair.
Open Communications 10dHysterectomy (4:50 PM d 4:55 PM)
Operative Outcomes and Complications: Robotic Versus Abdominal Hysterectomy for Complicated Benign Cases Beilan JA,1 Boardman LA,1 Johnson TR,1 Ahmad S,2 Bigsby GE IV,2 Finkler NJ,2 Holloway RW.2 1University of Central Florida College of Medicine, Orlando, Florida; 2Florida Hospital Cancer Institute, Orlando, Florida Study Objective: To compare patient characteristics and operative outcomes among a cohort of women undergoing robotic-assisted laparoscopic hysterectomy (RALH) or abdominal hysterectomy (AH) for management of benign disease with complex pathology. Design: This retrospective cohort study compared patients undergoing RALH between May 2006 and May 2009 to patients undergoing AH between July 2005 and May 2006. Demographic data, medical history, information on operative indications, findings, and complications were collected and analyzed. Setting: This study examined a population of women presenting to the Florida Hospital Gynecology Oncology (FHGO) Center for the management of non-malignant complex gynecologic pathology (e.g., leiomyomata, endometriosis, adenomyosis, benign ovarian masses). Patients: Women were eligible for inclusion under the following conditions: no pre- or post-operative evidence of malignancy, postoperative follow-up of R 6 months, and medical record completion of R 75%. Intervention: As this study retrospectively examined the operative outcomes of robotic versus abdominal hysterectomy, there was no intervention. Measurements and Main Results: Compared to AH patients (n = 103), RALH patients (n = 245) were less likely to have significant comorbidities (e.g., diabetes) and more likely to be of normal weight. RALH patients were less likely to have uterine weights of R500g or an adnexal or pelvic mass preoperatively. Although mean operative time was longer for RALH patients (99.8 versus 59.8 minutes), RALH resulted in reduced blood loss, reduced length of stay, and fewer wound infections postoperatively. After controlling for variables significantly associated with operative time (e.g., need for additional procedures including lysis of adhesions; BMIR40 kg/m2), mean operative time remained longer for RALH patients (adjusted means, 102.9 mins versus 52.4 mins). Early case status (i.e., first 25 RALH cases for each surgeon) was also significantly associated with longer operative times for RALH patients. Conclusion: RALH is a safe and effective option for the management of patients with complex pathology, irrespective of uterine weight or patient BMI. 165
Video Session 4dUrogynecology (3:20 PM d 3:27 PM)
Removal of Symptomatic Monarc Mesh Redwine DB. Gynecology, St. Charles Medical Center, Bend, Oregon A 68 year old female awoke from a Monarc sling procedure with right buttock pain. She developed worsening pain and leg weakness. She had point tenderness anterior to the right sacrospinous process. Laparoscopic radical dissection of the right pelvic sidewall found the fibrotic area associated with vitrification of the mesh material. The fibrotic area was removed and the patient experienced some improvement in her symptoms, although she is still bothered by lingering right leg weakness and pelvic pain. Surgical mesh behavior in the body is unpredictable and can be a cause of pain.
Video Session 4dUrogynecology (3:28 PM d 3:34 PM)
Laparoscopic Native-Tissue Uterine Suspension; a Novel Modification To Enhance Anterior Support Jeppson PC, Rardin CR. Division of Urogynecology and Reconstructive Pelvic Surgery, Alpert Medical School of Brown University, Providence, Rhode Island
167
Video Session 4dUrogynecology (3:35 PM d 3:42 PM)
Microlaparoscopy in Urogynecology: LSH and Sacrocervicopexy Rosenblatt PL, Adams SR, Shapiro A. Division of Urogynecology, Mount Auburn Hospital/Harvard Medical School, Cambridge, Massachusetts Objective: To describe the technique of using 3.5 mm trocars to reduce incision size and improve cosmesis during laparoscopic supracervical hysterectomy and sacrocervicopexy. Description: A 5 mm laparoscope is placed through the umbilicus and 3.5 mm trocars are placed in the right and left lower quadrants and in the suprapubic position. A standard approach to LSH is performed using a 3 mm bipolar instrument for coagulation. A 15 mm CISH instrument is used to core the cervix and remove the endocervical canal and surrounding cervical stroma. A disposable morcellator is introduced transvaginally through the cervical defect and transcervical morcellation is performed. Following morcellation, the 16 mm cannula becomes an access port during sacrocervicopexy for insertion and removal of mesh and sutures. Conclusion: We describe the technique of using 3.5 mm trocars and a 16 mm transcervical access port to reduce incision size during laparoscopic supracervical hysterectomy and sacrocervicopexy. 168
Video Session 4dUrogynecology (3:43 PM d 3:47 PM)
Minimally Invasive Midline Surgery ‘‘M-I-M-S’’ Using a Novel Suturing Technique for Sacrocervicopexy Apostolis CA, Adelowo A, DiSciullo AJ. Division of Urogynecology, Mount Auburn Hospital, Cambrdige, Massachusetts Single port sugery enables gynecologic surgeons to perform laparoscopic surgery through a single umbilical incision thereby eliminating the need for multiple ports. Single port surgery has been used for many different procedures including salpingo-Oopherectomy, supracervical hysterectomy and ovarian cyst removal. Its utility has not been extensively tested with pelvic reconstructive procedures, such as sacrocervicopexy, due to the advanced suturing skills and tissue manipulation needed to safely perfrom these procedure. We present a video introducing the ‘‘M-I-M-S’’ method for single port suturing. The concept behind this method is to introduce instruments through the abdominal mid-line, the line alba, thereby avoiding muscle splitting trocar placement. This method uses the 2.8mm Berci fascial closure device. We will demonstate the use of this instrument to facilitate laparoscopic suturing during single port surgery.