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Predictors of Surgical Approach to Myomectomies by Geographic Location
Abstracts / Journal of Minimally Invasive Gynecology 26 (2019) S1−S97 Arden D*. Minimally Invasive Gynecologic Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA *Corresponding author.
S85 Open Communications 24: Laparoscopy (3:05 PM − 4:05 PM) 3:33 PM
Video Objective: This educational video reviews the important retroperitoneal anatomy of the pelvic sidewall, including the ureter, the uterine artery as it emanates from the internal iliac artery, and the pararectal and paravesical spaces. Setting: Knowledge of retroperitoneal anatomy and the ability to safely explore the pelvic sidewall are essential skills for any gynecologic surgeon. Interventions: A simple schematic is shown to demonstrate the anatomic relationship between important retroperitoneal structures. Then, a surgical video is presented to demonstrate the same anatomy in an actual case. Conclusion: This video presents the essential retroperitoneal anatomy of the pelvic sidewall in a clear manner, and demonstrates a simple technique for laparoscopically identifying these structures. Open Communications 24: Laparoscopy (3:05 PM − 4:05 PM) 3:26 PM Association Between Myomectomy and Placenta Accreta Spectrum Kim JS,1,* Movilla PR,2 Lager JC1. 1UCSF, San Francisco, CA; 2 Minimally Invasive Gynecologic Surgery, Newton Wellesley Hospital, Newton, MA *Corresponding author. Study Objective: To examine the relationship between prior myomectomy and placenta accreta spectrum (PAS). Design: A retrospective chart review of all laparoscopic and abdominal myomectomies performed between 2014 - 2016. Obstetrical outcomes following surgery were collected through April 2019. Setting: An academic hospital with a comprehensive fibroid treatment center and a multidisciplinary treatment team dedicated to the management of placenta accreta. Patients or Participants: All patients who underwent a laparoscopic myomectomy (standard and robotic-assisted) or abdominal myomectomy between 2014 - 2016. Interventions: Demographics, pelvic imaging, intraoperative findings, fibroid burden on final pathology, and future mode of delivery recommendations were collected for each procedure. Subsequent obstetrical outcomes including clinical pregnancy, antepartum imaging suspicious for PAS, mode of delivery, clinical diagnosis of PAS, and pathologic PAS were collected for all patients. Measurements and Main Results: Of 315 patients who underwent myomectomy between 2014 - 2016, 43 patients subsequently became pregnant, resulting in 23 deliveries (7.3%). 16 of 20 patients underwent a cesarean delivery due to history of a prior myomectomy, 13 of which had a documented endometrial cavity entry at time of myomectomy. There were three cases of clinical PAS at time of delivery, all associated with a prior abdominal myomectomy. Two cases had PAS confirmed on final pathology. Two cases were associated with possible intrauterine synechiae identified during a uterine cavity evaluation following myomectomy, prior to conception. Only one case had antepartum imaging concerning for PAS. There were no cases of PAS amongst patients who had undergone a laparoscopic myomectomy. Conclusion: PAS was associated with prior abdominal but not laparoscopic myomectomy. The subsequent development of intrauterine synechiae following abdominal myomectomy may be an identifiable finding during postoperative uterine cavity evaluation. This finding may help stratify the risk of PAS following myomectomy prior to conception, and better guide preoperative risk counseling prior to cesarean delivery.
Laparoscopic Management of Exogenic Cesarean Section Pregnancy with Transient Uterine Artery Clipping Heredia F,1,2,* Donetch G,3 Ramos D,4 Escalona JR,3,5,6 Hinostroza M3,7. 1 Departamento de Ginecologıa y Obstetricia, Universidad de Concepcion, Concepci on, Chile; 2Unidad de cirugıa mınimamente invasiva y rob otica, Clınica Universitaria de Concepci on, Concepci on, Chile; 3Hospital Las on Ginecologıa, Hospital Regional de Higueras, Talcahuano, Chile; 4Secci Concepci on, Chiguayante, Chile; 5Unidad de cirugıa minimamente invasiva y rob otica, Clinica Universitaria de Concepcion, Concepci on, Chile; 6Departamento de Obstetricia y Ginecologia, Universidad de Concepcion, Concepci on, Chile; 7Departamento de Ginecologıa y Obstetricia, Universidad de Concepci on, Concepci on, Chile *Corresponding author. Video Objective: To show the laparoscopic management of a c-section scar pregnancy aided by transient uterine artery clipping to limit bleeding. Setting: 31 year old patient with a 7 week exogenic form of c-section scar pregnancy. Interventions: Laparoscopic resection of a c-section scar pregnancy. Conclusion: Laparoscopic management of C-section scar pregnancy provides the opportunity to repair the cesarean scar, thus avoiding future scar pregnancies.
Open Communications 24: Laparoscopy (3:05 PM − 4:05 PM) 3:40 PM Predictors of Surgical Approach to Myomectomies by Geographic Location McMahon ME,1,* Frost AS,1 Smith AJB,1 Patzkowsky KE2. 1Department of Gynecology & Obstetrics, Johns Hopkins School of Medicine, Baltimore, MD; 2Division of Minimally Invasive Gynecologic Surgery, Johns Hopkins School of Medicine, Baltimore, MD *Corresponding author. Study Objective: To analyze patient and hospital characteristics, stratified by geographic location, among women undergoing minimally invasive and abdominal myomectomies. Design: Data was abstracted from the 2010-2014 National Inpatient Sample of women ages 18-50 years undergoing myomectomy for fibroids. We used a multivariate logistic regression to analyze temporal and geographic trends in minimally-invasive (laparoscopic and robotic) and abdominal myomectomy by patient factors (age, race, insurance, income subgroups) and hospital characteristics (teaching status, forprofit status, size). Setting: United States. Patients or Participants: 124,880 women ages 18-50 years undergoing inpatient myomectomy for fibroids. Interventions: N/A Measurements and Main Results: Of the 124,880 women undergoing myomectomy for fibroids, 7% underwent minimally invasive myomectomy (MIM) and 93% underwent abdominal myomectomy. The percentage of MIM by geographic region was: South 37.6%, West 22.7%, North 21.8%, and Midwest 17.9%. In all geographic regions, women aged 41-50 had higher odds of undergoing MIM compared to younger women [North OR 2.21 95%CI 1.57 − 3.12, South OR 4.15 95%CI 3.14 − 5.50, Midwest OR 7.25 95%CI 4.36 − 12.05, West OR 4.57 95%CI 3.00- 6.96]. White women also had higher odds of undergoing MIM in the North, South, and West compared to women of other races
S86 [North OR 1.53 95%CI 1.08-2.17, South OR 1.51 95%CI 1.09-2.10, West OR 1.83 95%CI 1.32-2.54]. In the South, West, and Midwest, teaching hospitals had lower odds of performing MIM [South OR 0.71 95%CI .60- .85, Midwest OR .57 95%CI .43-.77, West OR .76 95%CI .60-.95]. Large hospitals in the North and West had lower odds of performing MIM [North OR 0.77 95%CI .62-.97, West OR .76 95%CI .60-.95]. Conclusion: Utilization of MIM is low throughout the US with further regional and age disparities. MIM is more likely to be performed in older aged women and in the South. Open Communications 24: Laparoscopy (3:05 PM − 4:05 PM) 3:47 PM Trends and Risk Factors for Vaginal Cuff Dehiscence After Laparoscopic Hysterectomy Das D,1,* Sinha A,2 Yao M,3 Michener CM4. 1Women’s Health Institute, Department of Obstetrics and Gynecology, Cleveland Clinic, Cleveland, OH; 2Case Western Reserve University School of Medicine, Cleveland, OH; 3Department of Quantitative Health Sciences, Section of Biostatistics, Cleveland Clinic, Cleveland, OH; 4Women’s Health Institute, Department of Gynecologic Oncology, Cleveland Clinic, Cleveland, OH *Corresponding author. Study Objective: Primary objective: Assess the effect of the route of vaginal cuff closure on the incidence of vaginal cuff dehiscence (VCD) in laparoscopic hysterectomy. Secondary objectives: Assess patient and surgical risk factors associated with VCD, the rate of intra- and perioperative complications by route of closure, and the impact of surgeon volume on complications. Design: Retrospective chart review with case-control component. Setting: Tertiary care referral center. Patients or Participants: 1277 women underwent laparoscopic (LH) or robotic-assisted (RAH) hysterectomy in 2016 and met inclusion criteria. 26 cases of VCD were identified from 2009 through 2016. Interventions: A retrospective comparison of patients with vaginal (VCC) and laparoscopic (LCC) cuff closure undergoing LH and RAH in 2016. Patients with VCD (n=26) were matched by route of cuff closure to the next seven hysterectomies (n=182) which became controls. Measurements and Main Results: In 2016, there were 8 cases of VCD (0.63%). There was no difference between LCC=7/988 (0.71%) and VCC 1/289 (0.35%, p=0.49). 7 VCD cases were performed by high volume surgeons (>30 hysterectomies per year) who were more likely to perform LCC and use barbed suture (p<0.001). However, there were no significant differences in rates of perioperative complications or surgeon volume between routes of cuff closure. Case-control patients differed in smoking status (p=0.010) and history of prior laparotomy (p=0.017). Logistic regression showed increasing age (OR 0.95, CI 0.91-0.99) and increasing BMI (OR 0.98, CI 0.83-0.97) were protective for VCD. Conclusion: VCD is a rare but serious complication of laparoscopic hysterectomy. Despite previous studies, we did not find a significant difference in VCD or intra- and perioperative complications by route of cuff closure or surgeon volume. Given the lack of evidence favoring one route of cuff closure, we recommend surgeons employ the closure technique they are best accustomed with to optimize patient outcomes. Open Communications 24: Laparoscopy (3:05 PM − 4:05 PM)
Abstracts / Journal of Minimally Invasive Gynecology 26 (2019) S1−S97 Gynecology, Mount Sinai Hospital & Women’s College Hospital, Toronto, ON, Canada *Corresponding author. Video Objective: The purpose of this video is to demonstrate three approaches to uterine artery occlusion at time of myomectomy as a bloodsparing intra-operative technique. Setting: Patients undergoing laparoscopic myomectomy underwent a uterine artery occlusion prior to any uterine incision. Interventions: A step-wise approach is applied prior to beginning the myomectomy portion of the procedure which includes the following: 1) Selecting the appropriate approach to uterine artery occlusion (lateral vs. posterior vs. anterior) based on individual anatomy; 2) identification of relevant anatomy and important landmarks for the procedure 3) isolating the uterine artery and identifying the ureter; 4) occluding the uterine artery. Conclusion: Uterine artery occlusion can be performed by three different approaches, as have been demonstrated in this video. As evidenced in the literature, this represents a safe and effective method of limiting blood loss and blood transfusion, albeit at slightly longer operative times. Open Communications 25: Urogynecology (4:10 PM − 5:10 PM) 4:10 PM Laparoscopic Creation of a Neovagina in MayerRokitansky-K€ uster-Hauser Syndrome Escalona JR,1,2,3,* Heredia F,4 Donetch G,3 Hinostroza M4. 1 Departamento de Obstetricia y Ginecologia, Universidad de Concepcion, otica, Concepci on, Chile; 2Unidad de cirugıa minimamente invasiva y rob Clinica Universitaria de Concepcion, Concepci on, Chile; 3Hospital Las Higueras, Talcahuano, Chile; 4Departamento de Ginecologıa y Obstetricia, Universidad de Concepci on, Concepci on, Chile *Corresponding author. Video Objective: To show the step by step procedure of a neovagina creation in Mayer-Rokitansky-K€uster-Hauser Syndrome. Setting: 22-year-old patient with primary amenorrhea, normal feminine phenotype development and vaginal agenesis on clinical examination. Pelvic ultrasound noted uterine agenesis. Mayer-Rokitansky-K€uster-Hauser Syndrome was diagnosed. Interventions: A Neovagina was created with simultaneous laparoscopic and perineal approach. Surgery lasted 1 hour. Patient uses dilators to maintain a functional neovagina. Conclusion: We believe this technique is simple, requires no special instruments and is fully reproductible with basic laparoscopic and vaginal surgical training. A correct understanding of surgical anatomy in each individual case warrants excellent results. Open Communications 25: Urogynecology (4:10 PM − 5:10 PM) 4:17 PM Levator Avulsion: A Review of Surgical Anatomy and Repair Technique for Primary Posterior Perineal Hernias Shu MK,1,* Eddib A2. 1University at Buffalo, Buffalo, NY; 2Minimally Invasive Advanced Pelvic Floor Surgery Fellowship, Millard Fillmore Suburban Hospital, Williamsville, NY *Corresponding author.
3:54 PM Approach to Uterine Artery Occlusion at Myomectomy Zakhari A,1,* Sanders AP,2 Murji A1. 1Department of Obstetrics and Gynecology, Mount Sinai Hospital, Toronto, ON, Canada; 2Obstetrics and
Video Objective: Perineal hernias are exceptionally uncommon gynecologic pathologies that may have a drastic impact on women’s health. Hernias that contain pelvic visceral structures present an especially unique challenge that requires immediate attention. Evidence is lacking as to the
S85 Open Communications 24: Laparoscopy (3:05 PM − 4:05 PM) 3:33 PM
Video Objective: This educational video reviews the important retroperitoneal anatomy of the pelvic sidewall, including the ureter, the uterine artery as it emanates from the internal iliac artery, and the pararectal and paravesical spaces. Setting: Knowledge of retroperitoneal anatomy and the ability to safely explore the pelvic sidewall are essential skills for any gynecologic surgeon. Interventions: A simple schematic is shown to demonstrate the anatomic relationship between important retroperitoneal structures. Then, a surgical video is presented to demonstrate the same anatomy in an actual case. Conclusion: This video presents the essential retroperitoneal anatomy of the pelvic sidewall in a clear manner, and demonstrates a simple technique for laparoscopically identifying these structures. Open Communications 24: Laparoscopy (3:05 PM − 4:05 PM) 3:26 PM Association Between Myomectomy and Placenta Accreta Spectrum Kim JS,1,* Movilla PR,2 Lager JC1. 1UCSF, San Francisco, CA; 2 Minimally Invasive Gynecologic Surgery, Newton Wellesley Hospital, Newton, MA *Corresponding author. Study Objective: To examine the relationship between prior myomectomy and placenta accreta spectrum (PAS). Design: A retrospective chart review of all laparoscopic and abdominal myomectomies performed between 2014 - 2016. Obstetrical outcomes following surgery were collected through April 2019. Setting: An academic hospital with a comprehensive fibroid treatment center and a multidisciplinary treatment team dedicated to the management of placenta accreta. Patients or Participants: All patients who underwent a laparoscopic myomectomy (standard and robotic-assisted) or abdominal myomectomy between 2014 - 2016. Interventions: Demographics, pelvic imaging, intraoperative findings, fibroid burden on final pathology, and future mode of delivery recommendations were collected for each procedure. Subsequent obstetrical outcomes including clinical pregnancy, antepartum imaging suspicious for PAS, mode of delivery, clinical diagnosis of PAS, and pathologic PAS were collected for all patients. Measurements and Main Results: Of 315 patients who underwent myomectomy between 2014 - 2016, 43 patients subsequently became pregnant, resulting in 23 deliveries (7.3%). 16 of 20 patients underwent a cesarean delivery due to history of a prior myomectomy, 13 of which had a documented endometrial cavity entry at time of myomectomy. There were three cases of clinical PAS at time of delivery, all associated with a prior abdominal myomectomy. Two cases had PAS confirmed on final pathology. Two cases were associated with possible intrauterine synechiae identified during a uterine cavity evaluation following myomectomy, prior to conception. Only one case had antepartum imaging concerning for PAS. There were no cases of PAS amongst patients who had undergone a laparoscopic myomectomy. Conclusion: PAS was associated with prior abdominal but not laparoscopic myomectomy. The subsequent development of intrauterine synechiae following abdominal myomectomy may be an identifiable finding during postoperative uterine cavity evaluation. This finding may help stratify the risk of PAS following myomectomy prior to conception, and better guide preoperative risk counseling prior to cesarean delivery.
Laparoscopic Management of Exogenic Cesarean Section Pregnancy with Transient Uterine Artery Clipping Heredia F,1,2,* Donetch G,3 Ramos D,4 Escalona JR,3,5,6 Hinostroza M3,7. 1 Departamento de Ginecologıa y Obstetricia, Universidad de Concepcion, Concepci on, Chile; 2Unidad de cirugıa mınimamente invasiva y rob otica, Clınica Universitaria de Concepci on, Concepci on, Chile; 3Hospital Las on Ginecologıa, Hospital Regional de Higueras, Talcahuano, Chile; 4Secci Concepci on, Chiguayante, Chile; 5Unidad de cirugıa minimamente invasiva y rob otica, Clinica Universitaria de Concepcion, Concepci on, Chile; 6Departamento de Obstetricia y Ginecologia, Universidad de Concepcion, Concepci on, Chile; 7Departamento de Ginecologıa y Obstetricia, Universidad de Concepci on, Concepci on, Chile *Corresponding author. Video Objective: To show the laparoscopic management of a c-section scar pregnancy aided by transient uterine artery clipping to limit bleeding. Setting: 31 year old patient with a 7 week exogenic form of c-section scar pregnancy. Interventions: Laparoscopic resection of a c-section scar pregnancy. Conclusion: Laparoscopic management of C-section scar pregnancy provides the opportunity to repair the cesarean scar, thus avoiding future scar pregnancies.
Open Communications 24: Laparoscopy (3:05 PM − 4:05 PM) 3:40 PM Predictors of Surgical Approach to Myomectomies by Geographic Location McMahon ME,1,* Frost AS,1 Smith AJB,1 Patzkowsky KE2. 1Department of Gynecology & Obstetrics, Johns Hopkins School of Medicine, Baltimore, MD; 2Division of Minimally Invasive Gynecologic Surgery, Johns Hopkins School of Medicine, Baltimore, MD *Corresponding author. Study Objective: To analyze patient and hospital characteristics, stratified by geographic location, among women undergoing minimally invasive and abdominal myomectomies. Design: Data was abstracted from the 2010-2014 National Inpatient Sample of women ages 18-50 years undergoing myomectomy for fibroids. We used a multivariate logistic regression to analyze temporal and geographic trends in minimally-invasive (laparoscopic and robotic) and abdominal myomectomy by patient factors (age, race, insurance, income subgroups) and hospital characteristics (teaching status, forprofit status, size). Setting: United States. Patients or Participants: 124,880 women ages 18-50 years undergoing inpatient myomectomy for fibroids. Interventions: N/A Measurements and Main Results: Of the 124,880 women undergoing myomectomy for fibroids, 7% underwent minimally invasive myomectomy (MIM) and 93% underwent abdominal myomectomy. The percentage of MIM by geographic region was: South 37.6%, West 22.7%, North 21.8%, and Midwest 17.9%. In all geographic regions, women aged 41-50 had higher odds of undergoing MIM compared to younger women [North OR 2.21 95%CI 1.57 − 3.12, South OR 4.15 95%CI 3.14 − 5.50, Midwest OR 7.25 95%CI 4.36 − 12.05, West OR 4.57 95%CI 3.00- 6.96]. White women also had higher odds of undergoing MIM in the North, South, and West compared to women of other races
S86 [North OR 1.53 95%CI 1.08-2.17, South OR 1.51 95%CI 1.09-2.10, West OR 1.83 95%CI 1.32-2.54]. In the South, West, and Midwest, teaching hospitals had lower odds of performing MIM [South OR 0.71 95%CI .60- .85, Midwest OR .57 95%CI .43-.77, West OR .76 95%CI .60-.95]. Large hospitals in the North and West had lower odds of performing MIM [North OR 0.77 95%CI .62-.97, West OR .76 95%CI .60-.95]. Conclusion: Utilization of MIM is low throughout the US with further regional and age disparities. MIM is more likely to be performed in older aged women and in the South. Open Communications 24: Laparoscopy (3:05 PM − 4:05 PM) 3:47 PM Trends and Risk Factors for Vaginal Cuff Dehiscence After Laparoscopic Hysterectomy Das D,1,* Sinha A,2 Yao M,3 Michener CM4. 1Women’s Health Institute, Department of Obstetrics and Gynecology, Cleveland Clinic, Cleveland, OH; 2Case Western Reserve University School of Medicine, Cleveland, OH; 3Department of Quantitative Health Sciences, Section of Biostatistics, Cleveland Clinic, Cleveland, OH; 4Women’s Health Institute, Department of Gynecologic Oncology, Cleveland Clinic, Cleveland, OH *Corresponding author. Study Objective: Primary objective: Assess the effect of the route of vaginal cuff closure on the incidence of vaginal cuff dehiscence (VCD) in laparoscopic hysterectomy. Secondary objectives: Assess patient and surgical risk factors associated with VCD, the rate of intra- and perioperative complications by route of closure, and the impact of surgeon volume on complications. Design: Retrospective chart review with case-control component. Setting: Tertiary care referral center. Patients or Participants: 1277 women underwent laparoscopic (LH) or robotic-assisted (RAH) hysterectomy in 2016 and met inclusion criteria. 26 cases of VCD were identified from 2009 through 2016. Interventions: A retrospective comparison of patients with vaginal (VCC) and laparoscopic (LCC) cuff closure undergoing LH and RAH in 2016. Patients with VCD (n=26) were matched by route of cuff closure to the next seven hysterectomies (n=182) which became controls. Measurements and Main Results: In 2016, there were 8 cases of VCD (0.63%). There was no difference between LCC=7/988 (0.71%) and VCC 1/289 (0.35%, p=0.49). 7 VCD cases were performed by high volume surgeons (>30 hysterectomies per year) who were more likely to perform LCC and use barbed suture (p<0.001). However, there were no significant differences in rates of perioperative complications or surgeon volume between routes of cuff closure. Case-control patients differed in smoking status (p=0.010) and history of prior laparotomy (p=0.017). Logistic regression showed increasing age (OR 0.95, CI 0.91-0.99) and increasing BMI (OR 0.98, CI 0.83-0.97) were protective for VCD. Conclusion: VCD is a rare but serious complication of laparoscopic hysterectomy. Despite previous studies, we did not find a significant difference in VCD or intra- and perioperative complications by route of cuff closure or surgeon volume. Given the lack of evidence favoring one route of cuff closure, we recommend surgeons employ the closure technique they are best accustomed with to optimize patient outcomes. Open Communications 24: Laparoscopy (3:05 PM − 4:05 PM)
Abstracts / Journal of Minimally Invasive Gynecology 26 (2019) S1−S97 Gynecology, Mount Sinai Hospital & Women’s College Hospital, Toronto, ON, Canada *Corresponding author. Video Objective: The purpose of this video is to demonstrate three approaches to uterine artery occlusion at time of myomectomy as a bloodsparing intra-operative technique. Setting: Patients undergoing laparoscopic myomectomy underwent a uterine artery occlusion prior to any uterine incision. Interventions: A step-wise approach is applied prior to beginning the myomectomy portion of the procedure which includes the following: 1) Selecting the appropriate approach to uterine artery occlusion (lateral vs. posterior vs. anterior) based on individual anatomy; 2) identification of relevant anatomy and important landmarks for the procedure 3) isolating the uterine artery and identifying the ureter; 4) occluding the uterine artery. Conclusion: Uterine artery occlusion can be performed by three different approaches, as have been demonstrated in this video. As evidenced in the literature, this represents a safe and effective method of limiting blood loss and blood transfusion, albeit at slightly longer operative times. Open Communications 25: Urogynecology (4:10 PM − 5:10 PM) 4:10 PM Laparoscopic Creation of a Neovagina in MayerRokitansky-K€ uster-Hauser Syndrome Escalona JR,1,2,3,* Heredia F,4 Donetch G,3 Hinostroza M4. 1 Departamento de Obstetricia y Ginecologia, Universidad de Concepcion, otica, Concepci on, Chile; 2Unidad de cirugıa minimamente invasiva y rob Clinica Universitaria de Concepcion, Concepci on, Chile; 3Hospital Las Higueras, Talcahuano, Chile; 4Departamento de Ginecologıa y Obstetricia, Universidad de Concepci on, Concepci on, Chile *Corresponding author. Video Objective: To show the step by step procedure of a neovagina creation in Mayer-Rokitansky-K€uster-Hauser Syndrome. Setting: 22-year-old patient with primary amenorrhea, normal feminine phenotype development and vaginal agenesis on clinical examination. Pelvic ultrasound noted uterine agenesis. Mayer-Rokitansky-K€uster-Hauser Syndrome was diagnosed. Interventions: A Neovagina was created with simultaneous laparoscopic and perineal approach. Surgery lasted 1 hour. Patient uses dilators to maintain a functional neovagina. Conclusion: We believe this technique is simple, requires no special instruments and is fully reproductible with basic laparoscopic and vaginal surgical training. A correct understanding of surgical anatomy in each individual case warrants excellent results. Open Communications 25: Urogynecology (4:10 PM − 5:10 PM) 4:17 PM Levator Avulsion: A Review of Surgical Anatomy and Repair Technique for Primary Posterior Perineal Hernias Shu MK,1,* Eddib A2. 1University at Buffalo, Buffalo, NY; 2Minimally Invasive Advanced Pelvic Floor Surgery Fellowship, Millard Fillmore Suburban Hospital, Williamsville, NY *Corresponding author.
3:54 PM Approach to Uterine Artery Occlusion at Myomectomy Zakhari A,1,* Sanders AP,2 Murji A1. 1Department of Obstetrics and Gynecology, Mount Sinai Hospital, Toronto, ON, Canada; 2Obstetrics and
Video Objective: Perineal hernias are exceptionally uncommon gynecologic pathologies that may have a drastic impact on women’s health. Hernias that contain pelvic visceral structures present an especially unique challenge that requires immediate attention. Evidence is lacking as to the