Myosure Hysteroscopic Morcellation for the Management of Submucous Fibroids in an Out-Patient Hysteroscopy Setting

S102

Abstracts / Journal of Minimally Invasive Gynecology 22 (2015) S1–S253

259 The First Experience of Computer-Assisted Image Guidance in Laparoscopic Surgery: The Targeting Animation Guidance (TAG) System Galen DI,1 Hammill C,2 Spero R,1 Epstein GH.1 1Halt Medical, Inc., Brentwood, California; 2Gastrointestinal and Minimally Invasive Surgery Division, The Oregon Clinic, Portland, Oregon Study Objective: Determine the utility of a novel computer-assisted image guidance system to guide the radiofrequency volumetric thermal ablation (RFVTA) probe during laparoscopic targeting and ablation of uterine fibroids. Design: Observational, single user feasibility study. Setting: Outpatient surgery center. Patients: One gynecologic surgeon experienced in laparoscopic ultrasoundguided targeting and ablation of uterine fibroids, and five premenopausal women (mean age, 42.39.2 years) having 3 (range, 2–7) symptomatic subserosal, intramural, and/or submucosal uterine fibroids with diameters of 2.8 cm (range, 1.0–6.7 cm). Intervention: Electromagnetic Targeting Animation Guidance (TAG) System for aiding the placement of the RFVTA probe. Measurements and Main Results: Intraoperative computer-assisted image guidance is well established in neurosurgery, spinal surgery and head-and-neck surgery. The TAG System provides laparoscopic surgeons with the spatial relationship between the radiofrequency handpiece tip and the ultrasound plane. A virtual animation of the ultrasound probe combined with an avatar representing the radiofrequency probe illustrates the position and trajectory of the tip, allowing the surgeon to seedon ultrasounddthe intraoperative path of the tip into the fibroid. After each use of the TAG system, the surgeon indicated his degree of agreement (1–strongly disagree to 5–strongly agree) with statements regarding features of the TAG system. The surgeon strongly agreed (96%) or agreed (4%) with the helpfulness of the dynamic animation in targeting the fibroid, visualizing the positions of the transducer and handpiece within the pelvic cavity, reaching the fibroid quickly, and providing the surgeon with confidence when targeting the fibroid even during ‘‘out-of-plane’’ positioning of the handpiece. Conclusion: The TAG system is the first and only FDA-cleared commercial computer-assisted image guidance system for laparoscopic surgery. It displays the relationship of two moving instruments in the abdominal cavity in real-time. Under laparoscopic ultrasound, it provides a positive user experience by facilitating accurate tip placement during targeting and ablation of uterine fibroids. 260 Total Laparoscopic Hysterectomy: Single Surgeon Experience in a Regional Centre After Changing Uterine Manipulator and Surgical Technique Raymond S,1 Titiz H.2 1Newcastle Private Hospital, Newcastle, NSW, Australia; 2Evin Women’s Health, Brisbane, QLD, Australia Study Objective: Objective of this study is to demonstrate: 1. Data analysis of the total laparoscopic hysterectomies(TLHs) before and after changing uterine manipulator and surgical technique. 2. The effect on the clinical outcome after changing uterine manipulator and surgical technique for total laparoscopic hysterectomy. 3. Video demonstration of step-by-step surgical technique of TLH with the use of new utero-vaginal manipulator in easy and difficult cases. Design: This gynaecologist (the first author) has decided to do TLHs for all patients requiring non vaginal hysterectomy for benign disease in an unselected gynaecological population in 2011. Setting: Non metropolitan private hospital. Patients: 112 TLH procedures were planned from Jan 2011 to March 2014.In these cases, combination of Valtchev uterine manipulator and Mc Cartney tube were used(Historical group).

From April till December 2014, new instrumentation (Titiz utero-vaginal manipulator) and a standardized surgical technique starting with a laparoscopic anterior colpotomy were used in 52 TLH cases( New group). In both group, patient characteristics( eg age,BMI,history of previous surgery) were similar. Intervention: Total laparoscopic hysterectomy with Titiz uterovaginal manipulator and new surgical technique. Measurements and Main Results: New group has less mean operation time then historical group( 48 min vs 26 min).The uterus was bigger in new group(heaviest uterus:780gr vs 426 gr).Conversion to laparotomy rate was 10.6% in historical group and 0% in new group. Main reasons for conversion were big uterus and severe endometriosis requiring bowel resection. There were more vaginal cuff infection(3% vs 1.9%) and bladder injury (1.7% vs 0%) in historical group. Conclusion: The data and the surgeon’s experience show that introduction of the new instrumentation and standardised surgical technique has led to: Reduced operating time Reduced conversion to laparotomy rate Possible to complete TLH when there is big uterus or severe endometriosis requiring bowel resection Easier use of utero-vaginal manipulator when there is only inexperienced surgical and theatre staff assistance available Less bladder injury More cost- effectiveness 261 Myosure Hysteroscopic Morcellation for the Management of Submucous Fibroids in an Out-Patient Hysteroscopy Setting Rajesh SK, Guyer C. Gynaecology, Queen Alexandra Hospital, Portsmouth, Hampshire, United Kingdom Study Objective: Audit the use of Myosure hysteroscopic morcellator for removal of submucous fibroids in an ambulatory clinic setting as per NICE recommendations. Study the effectiveness and 1 year outcome of symptom relief. Design: Retrospective case note review of patients with histological diagnosis of leiomyoma who had removal of pathology with Myosure from January 2014 to December 2014. Setting: Outpatient hysteroscopy clinic at Queen Alexandra Hospital, Portsmouth, UK. Patients: Notes were available for 17 out of the 20 patients. Mean patient age was 58.6 years (range 43-86 years). Intervention: Myosure Tissue removal system for morcellation of submucous fibroids. Patients pre-medicated with Paracetamol, NSAID’S and Tramadol. Measurements and Main Results: 58.9% were post-menopausal whereas 41.1 % were pre-menopausal. Indications were menorrhagia (41.1%), PMB (41.1%) and incidental thickened endometrium (11.7%). Size of lesion varied from 1cm-5cm. Type 0, Type 1 and Type 2 fibroids were removed. Average fluid deficit was 495.3 ml. In a different study we had concluded that Myosure was well tolerated in the out-patient setting (mid-procedure median VAS score-5). All patients had successful removal of pathology apart from two partial myomectomies (calcified fibroids) and one failed myosure for patulous cervix. Pathology removed: Benign leiomyomas except one endometrioid adenocarcinoma. No complications were noted and only one patient required Tramadol in recovery who had endometrial ablation along with Myosure. Symptom resolution noted at 2-month follow up and data for 1-year follow up will be presented at the meeting. Conclusion: Submucous fibroids can be safely resected using a Myosure device in an out-patient setting. It is well tolerated with minimal complications and is very effective in management of abnormal uterine bleeding. The audit results will be disseminated through the local clinical governance meetings to increase the awareness among gynaecologists to

Abstracts / Journal of Minimally Invasive Gynecology 22 (2015) S1–S253 offer Outpatient Myosure procedures for submucous fibroid morcellation to all eligible patients.

S103

Conclusion: SP-LN may be a feasible and safe alternative for women with hydrosalpinx. However, further study is needed to confirm these preliminary results and explore obstetric outcomes following SP-LN.

262 Single-Port Laparoscopic Neosalpingostomy for Hydrosalpinx Ji HY, Yuk J-S, Lee JH. Obstetrics and Gynecology, MizMedi Hospital, Eulji University School of Medicine, Seoul, Korea Study Objective: To describe the surgical technique of and our initial experience with single-port laparoscopic neosalpingostomy (SP-LN) to treat hydrosalpinx. Design: Prospective observational study. Setting: University teaching hospital. Patients: Ten women who underwent SP-LN for hydrosalpinx between November 2011 and December 2014. Intervention: Single-port laparoscopic neosalpingostomy. Measurements and Main Results: The mean (range) age and body mass index of the women were 29.3 (21-36) years and 22.2 (17.7-27.1) kg/m2, respectively. Four women had a history of previous abdominal surgery; laparoscopic unilateral salpingectomy for tubal pregnancy was performed in two patients, laparoscopic appendectomy was performed in one patient, and laparotomy appendectomy was performed in one patient. Four women underwent unilateral SP-LN, and six women underwent bilateral SP-LN. The mean (range) operative time, hemoglobin change, return of bowel activity, and length of hospital stay were 91.5 (70-120) minutes, 0.7 (0.1-1.6) g/dL, 19.9 (7.1-25.4) hours, and 3.7 (3-4) days, respectively. No conversion to multi-port laparoscopy or laparotomy occurred. No surgical or wound complications were observed in any patient. Table 1. Clinical characteristics. Number (%)/ Mean (range) Number of patients Age (years) Parity Body mass index (kg/m2) Number of women with previous abdominal surgeries Laparoscopic unilateral salpingectomy for tubal pregnancy Laparoscopic appendectomy Laparotomic appendectomy

10 29.3 (21-36) 0.1 (0-1) 22.2 (17.7-27.1) 4 (40) 2 (20) 1 (10) 1 (10)

Data are presented as numbers (percentages) or means (ranges)

264 Initial Gynecologic Experience Using the VITOMÒ HD Exoscope for Vaginal Surgery Taylor B, Myers EM. Obstetrics and Gynecology/ Division of Female Pelvic Medicine and Reconstructive Surgery, Carolinas Healthcare System, Charlotte, North Carolina Study Objective: The purpose of this study was to evaluate the utility of a high definition optical system for use in vaginal surgery. Design: Prospective cohort. Setting: Academic affiliated community hospital. Patients: Patients undergoing vaginal surgery by faculty from the Division of Female. Pelvic Medicine and Reconstructive Surgery at Carolinas HealthCare System during our trial and evaluation of the VITOMÒ HD in gynecologic vaginal surgery. Intervention: The VITOMÒ HD exoscope (VITOM HD; Karl Storz Endoscopy GmbH, Tuttlingen, Germany) was used to provide surgical illumination and optimize optical visualization during four procedures: 1) Total vaginal hysterectomy and salpingectomy, 2) Mid urethral sling procedure, 3) Removal of a synthetic sling, and 4) Release of vaginal scar. Each procedure was performed under general endotracheal anesthesia with the patient in the lithotomy position. The patient’s legs were supported in YellowfinsÒ Elite Stirrups with Lift-AssistTM and standard overhead surgical surgical lights were utilized. The Lone Star APS RetractorTM (Cooper Surgical Lone Star Retractor System no. 3715) was also used for vaginal exposure during all cases. The VITOMÒ HD was attached to the surgical table after administration of anesthesia, sterile draping, and final positioning of the patient. The time to attach the support arm and optic unit was less than five minutes. Measurements and Main Results: All procedures were completed without complications. The subjective benefits of the VITOMÒ HD were optical magnification of the surgical field on HD monitors, improved illumination allowing for visualization of the entire vagina and into the peritoneal cavity following the hysterectomy. Ergonomically the operating surgeon subjectively noted less physical strain whether in the seated or standing positions. Conclusion: The VITOMÒ HD system provides unprecedented illumination and visualization during vaginal surgery. While this paper demonstrates the feasibility and benefits of the high definition optical system, future prospective study to formally evaluate these finding is needed.

Table 2. Operative outcomes (n = 10). Number (%)/ Mean (range) Operative time (minutes) Hemoglobin change (g/dL) Return of bowel activity (hours) Hospital stay (days) Primary surgery Unilateral SP-laparoscopic neosalpingostomy Bilateral SP-laparoscopic neosalpingostomy Concomitant surgeries SP-laparoscopic myomectomy SP-laparoscopic ovarian cystectomy Conversion to multiport laparoscopy or laparotomy

91.5 (70-120) 0.7 (0.1-1.6) 19.9 (7.1-25.4) 3.7 (3-4) 4 (40) 6 (60) 1 (10) 3 (30) 0 (0)

Data are presented as numbers (percentages) or means (standard deviations). SD = standard deviation; SP = single port

265 Vaginal Dilation in Mayer-Rokitansky-Kuster-Hauser (MRKH) Syndrome Ketheeswaran A,1 Morrisey J,2 Abbott J,1 Bennett M,1 Dudley J,1 Deans R.1 1University of New South Wales, Kensington, NSW, Australia; 2 Royal Hospital for Women, Sydney, NSW, Australia Study Objective: To evaluate intensive vaginal dilator therapy as a first line therapy for creation of a functional and anatomical neovagina in women with MRKH. Design: Retrospective cohort Study (II-3). Setting: Academic affiliated tertiary hospital, Sydney Australia. Patients: Women with MRKH undergoing intensive vaginal dilator treatment between 2000 and 2014. Intervention: One specialist nurse performed the intensive dilator treatment, consisting of several dilation sessions per day. Adjuvant