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New Approach to Laparoscopic Peritoneal Pull through Vaginoplasty
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Abstracts / Journal of Minimally Invasive Gynecology 26 (2019) S1−S97
Measurements and Main Results: 369,740 hysterectomies were included (48.4% abdominal; 28.3% laparoscopic; 23.3% vaginal). Mean age was 48.5 years (SD 11.2 years), and indications for surgery were menstrual bleeding disorders (29.7%), fibroids (23.7%), pelvic organ prolapse (19.8%), other(17.4%), endometriosis(5.8%) and pelvic pain(3.6%). National technicity index (proportion of vaginal and laparoscopic hysterectomies) increased (40.5%⟶63.2%). Abdominal hysterectomy decreased (59.5%⟶36.8%); laparoscopic increased (10.8%⟶38.6%); while, vaginal decreased (29.7%⟶24.5%). (p<0.05, all trends). Increasing technicity index was observed in all provinces, though with variable increase over time. (p<0.05, all trends), and variation was seen in relative risk (RR) of abdominal hysterectomy for FY2016/17. Manitoba(36.9%⟶44.4%; RR1.50,95%CI[1.43-1.58]*), Nova Scotia (46.4%⟶48.5%; RR1.39[1.31-1.48]*), New Brunswick(43.7%⟶50.3%; RR1.34[1.26-1.44]*), Newfoundland(35.3%⟶55.2%; RR1.21[1.10-1.33]*), Ontario (39.4%⟶63.0%, RR1.00[reference])Quebec(42.0%⟶61.8%; RR1.03[0.99-1.07]), Prince Edward Island(54.9%⟶64.3%; RR0.96[0.811.15]), Alberta(34.0%⟶64.3%; RR0.96[0.92-1.01]), British Columbia (43.4%⟶72.1%; RR 0.75[0.71-0.79]*), Saskatchewan(47.7%⟶83.9%; RR0.44[0.39-0.49]*). Conclusion: Minimally invasive hysterectomy for benign indication has increased significantly in Canada over the past decade. However, the increase reflects increasing use of laparoscopic hysterectomy with a declining use of vaginal hysterectomy. The variation between provinces represents a technicity gap that warrants further study and intervention.
Patients: Total laparoscopic hysterectomy for uterus greater than 800 grams. Interventions: In anterior approach, by making a bladder flap one can firstly detect and ligate uterine arteries to reduce bleeding. Measurements and Main Results: In the case of adenomyosis and endometriosis, bleeding from severe fibrosis may be encountered in the parametrium. Ligation of the uterine arteries first will help to avoid bleeding. Open the bladder flap wide and lifting it sufficiently and cutting the loose connective tissue caudally will expose the palpable ascending and inward vessel. That is the uterine artery. The separation between the uterine artery and the ureter opens Latzko’s pararectal space. In the case of fibroid, we find the ureter first as the broad ligament is more elastic allowing for stretching. By making the broad ligament tense, you can elevate the posterior leaf of broad ligament to separate the mesoureter. This procedure allows entry into Okabayashi’s pararectal space. The entry point is at about 1cm medially to the root of the lateral umbilical ligament. This space is avascular and stretches to easily find the mesoureter containing the ureter above it. Conclusion: Mastering an anterior approach and recognizing fascial layers contributes to our surgical toolbox in coping with more complicated hysterectomies.
Open Communications 8: Laparoscopy (3:05 PM − 4:05 PM)
EMIG Simulation Systems Construct Validation Trial: Laparoscopic Component Munro MG,1,* Advincula AP,2 Thayn K3. 1Obstetrics and Gynecology, University of California, Los Angeles and Kaiser Permanente, Los Angeles Medical Center, Los Angeles, CA; 2Obstetrics and Gynecology, Columbia University Medical Center, New York, NY; 3Kryterion Inc, Park City, UT *Corresponding author.
3:33 PM New Approach to Laparoscopic Peritoneal Pull through Vaginoplasty Saxena A,* Arora A, Teja GND, Jaiswal E. Tulip Multispeciality Hospital Pvt. Ltd, Sonepat, India *Corresponding author. Video Objective: To evaluate the outcome of new technique of laparoscopic peritoneal pull through vaginoplasty. Setting: Tertiary referral centre (Tulip Multispeciality Hospital). Interventions: The peritoneum was mobilized as much as possible from all around lateral pelvic wall we applied 4 stay sutures to the mobilized peritoneum (ant, post, Rt, Lt) and the same sutures were pulled through the vagina and tied to the introitus. Conclusion: Our technique appears to be an effective and safe surgical management option giving excellent normal vaginal function and patient satisfaction score was good. Open Communications 8: Laparoscopy (3:05 PM − 4:05 PM) 3:40 PM Mastering the Anterior Approach of Laparoscopic Hysterectomy for the Huge Uterus Shirane A,* Andou M, Ichikawa F, Shirane T, Sawada M, Sakate S. Obstetrics and Gynecology, Kurashiki Medical Center, Kurashiki, Japan *Corresponding author. Video Objective: To expand laparoscopic surgical skills, we need to strategies to cope with the very large uterus.Traditionally, there are three techniques to detect and mobilize the ureter and uterine artery: the anterior, lateral and posterior approach. Generally, the lateral approach is most common as one can easily detect the ureters transperitoneally at the rim of psoas muscle. But, in the case of a large and bulky uterus, advanced techniques are required. Design: Laparoscopic demonstration of fascial planes and surgical techniques used to cope with the huge uterus. Setting: Kurashiki medical center, private hospital, in Japan.
Open Communications 8: Laparoscopy (3:05 PM − 4:05 PM) 3:47 PM
Study Objective: Construct validation of the EMIG Laparoscopic Surgery Simulation System. Design: A prospective, controlled cohort comparison. Setting: Thirteen teaching institutions in the US and Canada and an AAGL Congress Patients or Participants: 221 subjects who fit one of 4 categories of exposure to laparoscopic surgery and surgical simulation: 77 novices within 100 days of starting posgraduate year 1 (PGY-1); 71 within the first 100 days of starting PGY-3; 30 American Board of Obstetrics and Gynecology (ABOG) certified and no additional fellowship training (“Proficient”); 43 who had completed the two-year Fellowship in Minimally Invasive Gynecologic Surgery (FMIGS). Interventions: Subjects were oriented to the simulation system and then tested under proctor supervision on the 5 EMIG laparoscopic exercises. These included the sleeve to peg transfer (L-1); the circular pattern cut (L2); extracorporeal knotting (L-3); intracorporeal knotting (L-4); and a running suture (L-5). Time and accuracy scoring were entered electronically on site, but sessions were video recorded and study materials such as cutting and suturing targets were labeled and stored for subsequent review to optimize data quality. Measurements and Main Results: Each exercise was timed, and a number of objective metrics recorded that reflected cutting and suturing accuracy and technique. Each exercise had a “time cap”; if a subject had not completed the exercise by the end of the allotted time, they were categorized “Did Not Complete” and the maximum time was entered for data analysis. Preliminary data analysis demonstrates that the novice group consistently demonstrated the poorest performance and the FMIGS cohort consistently the best. The PGY-3 and “Proficient” cohorts were generally similar to each other but each performed better than the PGY-1 group and well below the FMIGS group. Conclusion: The EMIG Laparoscopic Simulation System can be used to distinguish amongst PGY-1, PGY-3, Proficient and FMIGS subjects. FMIGS-trained subjects consistently had the best results with almost no “Did not Complete” outcomes.
Abstracts / Journal of Minimally Invasive Gynecology 26 (2019) S1−S97
Measurements and Main Results: 369,740 hysterectomies were included (48.4% abdominal; 28.3% laparoscopic; 23.3% vaginal). Mean age was 48.5 years (SD 11.2 years), and indications for surgery were menstrual bleeding disorders (29.7%), fibroids (23.7%), pelvic organ prolapse (19.8%), other(17.4%), endometriosis(5.8%) and pelvic pain(3.6%). National technicity index (proportion of vaginal and laparoscopic hysterectomies) increased (40.5%⟶63.2%). Abdominal hysterectomy decreased (59.5%⟶36.8%); laparoscopic increased (10.8%⟶38.6%); while, vaginal decreased (29.7%⟶24.5%). (p<0.05, all trends). Increasing technicity index was observed in all provinces, though with variable increase over time. (p<0.05, all trends), and variation was seen in relative risk (RR) of abdominal hysterectomy for FY2016/17. Manitoba(36.9%⟶44.4%; RR1.50,95%CI[1.43-1.58]*), Nova Scotia (46.4%⟶48.5%; RR1.39[1.31-1.48]*), New Brunswick(43.7%⟶50.3%; RR1.34[1.26-1.44]*), Newfoundland(35.3%⟶55.2%; RR1.21[1.10-1.33]*), Ontario (39.4%⟶63.0%, RR1.00[reference])Quebec(42.0%⟶61.8%; RR1.03[0.99-1.07]), Prince Edward Island(54.9%⟶64.3%; RR0.96[0.811.15]), Alberta(34.0%⟶64.3%; RR0.96[0.92-1.01]), British Columbia (43.4%⟶72.1%; RR 0.75[0.71-0.79]*), Saskatchewan(47.7%⟶83.9%; RR0.44[0.39-0.49]*). Conclusion: Minimally invasive hysterectomy for benign indication has increased significantly in Canada over the past decade. However, the increase reflects increasing use of laparoscopic hysterectomy with a declining use of vaginal hysterectomy. The variation between provinces represents a technicity gap that warrants further study and intervention.
Patients: Total laparoscopic hysterectomy for uterus greater than 800 grams. Interventions: In anterior approach, by making a bladder flap one can firstly detect and ligate uterine arteries to reduce bleeding. Measurements and Main Results: In the case of adenomyosis and endometriosis, bleeding from severe fibrosis may be encountered in the parametrium. Ligation of the uterine arteries first will help to avoid bleeding. Open the bladder flap wide and lifting it sufficiently and cutting the loose connective tissue caudally will expose the palpable ascending and inward vessel. That is the uterine artery. The separation between the uterine artery and the ureter opens Latzko’s pararectal space. In the case of fibroid, we find the ureter first as the broad ligament is more elastic allowing for stretching. By making the broad ligament tense, you can elevate the posterior leaf of broad ligament to separate the mesoureter. This procedure allows entry into Okabayashi’s pararectal space. The entry point is at about 1cm medially to the root of the lateral umbilical ligament. This space is avascular and stretches to easily find the mesoureter containing the ureter above it. Conclusion: Mastering an anterior approach and recognizing fascial layers contributes to our surgical toolbox in coping with more complicated hysterectomies.
Open Communications 8: Laparoscopy (3:05 PM − 4:05 PM)
EMIG Simulation Systems Construct Validation Trial: Laparoscopic Component Munro MG,1,* Advincula AP,2 Thayn K3. 1Obstetrics and Gynecology, University of California, Los Angeles and Kaiser Permanente, Los Angeles Medical Center, Los Angeles, CA; 2Obstetrics and Gynecology, Columbia University Medical Center, New York, NY; 3Kryterion Inc, Park City, UT *Corresponding author.
3:33 PM New Approach to Laparoscopic Peritoneal Pull through Vaginoplasty Saxena A,* Arora A, Teja GND, Jaiswal E. Tulip Multispeciality Hospital Pvt. Ltd, Sonepat, India *Corresponding author. Video Objective: To evaluate the outcome of new technique of laparoscopic peritoneal pull through vaginoplasty. Setting: Tertiary referral centre (Tulip Multispeciality Hospital). Interventions: The peritoneum was mobilized as much as possible from all around lateral pelvic wall we applied 4 stay sutures to the mobilized peritoneum (ant, post, Rt, Lt) and the same sutures were pulled through the vagina and tied to the introitus. Conclusion: Our technique appears to be an effective and safe surgical management option giving excellent normal vaginal function and patient satisfaction score was good. Open Communications 8: Laparoscopy (3:05 PM − 4:05 PM) 3:40 PM Mastering the Anterior Approach of Laparoscopic Hysterectomy for the Huge Uterus Shirane A,* Andou M, Ichikawa F, Shirane T, Sawada M, Sakate S. Obstetrics and Gynecology, Kurashiki Medical Center, Kurashiki, Japan *Corresponding author. Video Objective: To expand laparoscopic surgical skills, we need to strategies to cope with the very large uterus.Traditionally, there are three techniques to detect and mobilize the ureter and uterine artery: the anterior, lateral and posterior approach. Generally, the lateral approach is most common as one can easily detect the ureters transperitoneally at the rim of psoas muscle. But, in the case of a large and bulky uterus, advanced techniques are required. Design: Laparoscopic demonstration of fascial planes and surgical techniques used to cope with the huge uterus. Setting: Kurashiki medical center, private hospital, in Japan.
Open Communications 8: Laparoscopy (3:05 PM − 4:05 PM) 3:47 PM
Study Objective: Construct validation of the EMIG Laparoscopic Surgery Simulation System. Design: A prospective, controlled cohort comparison. Setting: Thirteen teaching institutions in the US and Canada and an AAGL Congress Patients or Participants: 221 subjects who fit one of 4 categories of exposure to laparoscopic surgery and surgical simulation: 77 novices within 100 days of starting posgraduate year 1 (PGY-1); 71 within the first 100 days of starting PGY-3; 30 American Board of Obstetrics and Gynecology (ABOG) certified and no additional fellowship training (“Proficient”); 43 who had completed the two-year Fellowship in Minimally Invasive Gynecologic Surgery (FMIGS). Interventions: Subjects were oriented to the simulation system and then tested under proctor supervision on the 5 EMIG laparoscopic exercises. These included the sleeve to peg transfer (L-1); the circular pattern cut (L2); extracorporeal knotting (L-3); intracorporeal knotting (L-4); and a running suture (L-5). Time and accuracy scoring were entered electronically on site, but sessions were video recorded and study materials such as cutting and suturing targets were labeled and stored for subsequent review to optimize data quality. Measurements and Main Results: Each exercise was timed, and a number of objective metrics recorded that reflected cutting and suturing accuracy and technique. Each exercise had a “time cap”; if a subject had not completed the exercise by the end of the allotted time, they were categorized “Did Not Complete” and the maximum time was entered for data analysis. Preliminary data analysis demonstrates that the novice group consistently demonstrated the poorest performance and the FMIGS cohort consistently the best. The PGY-3 and “Proficient” cohorts were generally similar to each other but each performed better than the PGY-1 group and well below the FMIGS group. Conclusion: The EMIG Laparoscopic Simulation System can be used to distinguish amongst PGY-1, PGY-3, Proficient and FMIGS subjects. FMIGS-trained subjects consistently had the best results with almost no “Did not Complete” outcomes.