- Email: [email protected]
Retrospective Analysis of 225 Cases Between Ligation of Uterine Arteries and Suturing of Uterine Vessels and Cervical Stump Ligation in Laparoscopic Supracervical Hysterectomy(LSH)
Abstracts / Journal of Minimally Invasive Gynecology 22 (2015) S1–S253
S209
Details of cases SI No
Case details
Procedure performed
Estimated blood loss (mls)
1 2 3
Ruptured left tubal ectopic pregnancy Ruptured right tubal ectopic Heterotropic pregnancy with ruptured right isthmic pregnancy Ovarian pregnancy post recent salpingectomy for previous ectopic pregnancy Ruptured isthmic pregnancy
Laparoscopic left salpingectomy Laparoscopic right salpingectomy Laparoscopic right salpingectomy
2500 3000 2000
Laparoscopic wedge resection of ovarian pregnancy Laparoscopic right salpingectomy
1000
1 day
4200
1 day
4 5
723 Abdominal Pregnancy – A Constant Location? A Case Report of an Omental Viable Pregnancy and Review of Literature Sharon A, Anderman S, Raviv S, Groisman G, Hallak M. Ob/Gyn, Hillel Yaffe, Hadera, Israel Study Objective: To report the first rare case of a viable omental pregnancy. Design: Case report. Setting: Department of Obstetrics and Gynecology of a university teaching hospital. Patients: A 37 years old woman. Intervention: Two laparoscopies. Measurements and Main Results: Main outcome measure: A first negative laparoscopy followed by a successful partial omentectomy in a second laparoscopy. Result: A 37 years old woman presented with mild vaginal bleeding, delay in menstruation and a positive BHCG. Via transvaginal ultrasound (TVS), a viable fetus was demonstrated on the left side. A laparoscopy was performed which showed normal both tubes and no sign of ectopic pregnancy. The tubes were removed together with a uterine curettage, while the histology thereafter, was negative. The next day TVS didn’t show the ectopic pregnancy any more. Four days later a sudden lower abdominal pain, hemoperitoneum, an ectopic pregnancy on the right side, and decreased in the hemoglobin were presented. The patient was rushed to operating room for a second laparoscopy, in which an omental ectopic pregnancy adhered to the right side was seen. Partial omentectomy was the treatment which ended the interesting story. This is the first documented case of omental pregnancy which firstly diagnosed with cardiac activity. Conclusion: An abdominal ectopic pregnancy, especially at the omentum, is a rare condition and difficult for diagnosis. A high level of suspicion should be taken in the presence of a negative laparoscopy.
724 Correlation Between the Number of Previous Pelvic Surgeries and Surgical Complications in Patients Undergoing Laparoscopic Hysterectomy Basurto-Diaz D,1 Flores-Mendoza H,1 Hernandez-Nieto CA,1 Garcia-Rodriguez LF.2 1Programa Multicentrico de Residencias Medicas, Tecnologico de Monterrey, Monterrey, Nuevo Leon, Mexico; 2Obstetrics and Gynecology, Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado de Nuevo Leon, Monterrey, Nuevo Leon, Mexico Study Objective: To analyze if a correlation exists between uterine size defined by final pathology-piece weight and the existence of surgical complications in women who underwent type VII total laparoscopic hysterectomy (LH). Design: A case-controlled, retrospective analysis. Continuous variables were expressed as means and standard deviations (SD) or medians and interquartile ranges (IQR), upon distribution analysis by AndersonDarling’s normality test. Statistical analysis to determine correlation
Blood obtained through salvage (mls) 1500 1300 1100
Duration of postoperative stay 1 day 2 days 3
between binary and quantitative variables was done with a binary logistic regression, establishing a 95% confidence interval (CI) and a p-value at \0.05. Setting: TECSalud healthcare system in Monterrey, northeastern Mexico. Patients: 235 consecutive patients undergoing type VII total LH performed from January 2008 through December 2014. Measurements and Main Results: Median patient age was 45 years (41-49 IQR) with a median 25.39 body mass index (21.4-28 IQR), a median history of pelvic surgeries of 2 (1-3 IQR). Median surgical time was 140 minutes (120-170 IQR) with a median 100 milliliters (50-300 IQR) of blood loss and a median in-hospital stay of 3 days (2-3 IQR). 14 or 6.6% or patients presented surgical complications, this group had a mean previous pelvic surgery history of 1.79 surgeries (1.37 SD) with a mean 176 minutes (50.3 SD) of surgical time. Binary logistic regression showed no evidence of statistical significant correlation between uterine weight and surgical complications (CI -0.463-0.265; p= 0.594). Conclusion: There is insufficient statistical evidence to determine that a correlation exists between the number of previous pelvic surgeries and the presence of surgical complications. Therefore, type VII total LH seems as a feasible and safe surgical procedure, resulting in a short hospital stay, with minimal blood loss, minimal operating time, and a low complication rate regardless of uterine weight.
725 Retrospective Analysis of 225 Cases Between Ligation of Uterine Arteries and Suturing of Uterine Vessels and Cervical Stump Ligation in Laparoscopic Supracervical Hysterectomy(LSH) Mun ST. Dept. of Ob/Gyn, Soon Chun Hyang University Hospital, Cheon An-si, Chung Nam, Republic of Korea Study Objective: To compare the efficacy and safety among three methods such as ligation of uterine vessels and suturing of uterine vessel and cervical stump ligation in LSH. Design: Retrospective analysis of 225 consecutive cases of LSH. Setting: University Hospital. Patients: 225 women (ages 33-53 yrs) undergoing Laparoscopic supracervical hysterectomy. 68 women was uterine vessel ligation group, 58 women was uterine vessel suturing group, 99 women cervical stump ligation. Intervention: Charts were reviewed to determine post-operative complications and surgical values. A comparison was made among three groups in post-operative hemoglobin, and hematocrits changes, operation time, blood loss during operation, post-operative drainage volume (n=225). Measurements and Main Results: There were no statistically significant difference among three groups in terms of age, indication for surgery, uterine size, body mass index, parity. There were significant difference in the average time of the procedure among three groups (stump ligation vs uterine vessel ligation vs uterine vessel suturing), 91.5min vs 69.0min vs 71 min (p\0.05). There were significant differences in blood loss, 145.4 ml vs 107.0ml vs 99 ml (p\0.05), change in hemoglobin, 1.52 vs 1.15 vs 1.11 (p\0.05) and hematocrit, 5.16 vs 3.78 vs 3.57 (p\0.05).
S210
Abstracts / Journal of Minimally Invasive Gynecology 22 (2015) S1–S253
stump ligation
Measurements and Main Results: There were 366 procedures coded as diagnostic laparoscopy and/or excision of peritoneal tissue performed during the study period. Of these, 55 were excluded for intrauterine device removal, hysterectomy or surgery only for bilateral tubal ligation. Of the remaining 311 cases, 149 were performed prior to fellowship trained MIGS surgeons joining the academic practice in January 2012. After the incident date, 162 cases were performed. Of the 149 procedures before the addition of the fellowship trained surgeons, none of the patients had intraoperative placement of LNG-IUDs. Following the addition of two MIGS trained surgeons, 21 LNG-IUDs were placed at the time of surgical treatment. The increase in procedures including concomitant intraoperative LNG-IUD placement after the incident date was statistically significant (p\0.0001). Conclusion: In our study there was a positive correlation between the faculty addition of MIGS trained surgeons and the incidence of intraoperative LNG-IUD placement. Practice patterns and physician influence amongst groups with fellowship-trained providers may provide additional insight to benign gynecologic disease management. Additional research is needed to determine if the LNG-IUD is an effective accompaniment to laparoscopic surgery and an effective postoperative treatment of diseases such as endometriosis and chronic pelvic pain.
Uterine vessel suture
727 Laparoscopic Uterine Cerclage: An Audit of Safety and Reproductive Outcomes Ma KKY, Edi-Osagie E. Gynaecology, St. Mary’s Hospital, Manchester, Greater Manchester, United Kingdom
Conclusion: Ligation of Uterine vessels and suturing of uterine vessels were safe and effective methods than ligation of stump in LSH.
726 Impact of Minimally Invasive Gynecologic Surgery Fellowship Training on Concomitant Levonorgestrel-Releasing Intrauterine Device Placement at the Time of Laparoscopic Surgery Vu C, Hernly E, Carey E, Swan K. University of Kansas Medical Center, Kansas City, Kansas Study Objective: To determine if training in Minimally Invasive Gynecologic Surgery (MIGS) is associated with an increased frequency of intraoperative levonorgestrel-releasing intrauterine device (LNG-IUD) placement for postoperative management of pelvic pain and endometriosis. Design: Retrospective chart review. Setting: University of Kansas Medical Center (KUMC). Patients: Pre-menopausal women age 18-50 years who underwent outpatient diagnostic laparoscopy and/or excision of peritoneal tissue from October 1, 2008 to March 31, 2015; 366 patients underwent surgery during this time period. Intervention: None
Study Objective: To determine the safety and efficacy of all cases of laparoscopic uterine cerclage performed in a tertiary referral centre in the last 5 years. Design: Retrospective clinical audit against National Institute of Clinical Excellence guidelines. Setting: Tertiary referral centre and university teaching hospital. Patients: All patients who underwent laparoscopic uterine cerclage from May 2010 to May 2014. Intervention: Laparoscopic insertion of uterine cerclage Measurements and Main Results: A total of five cases were identified. 100% of patients presented with a history of recurrent pregnancy loss or extreme premature labour (\26 weeks) despite the use of a prophylactic cervical cerclage. No intra-operative complications were noted. Mean intra-operative blood loss was 100ml, mean operating time was 92 minutes (range 68-121 min), no post-operative complications or readmissions was noted. 5 of 5 patients proceeded to spontanous conception. 4 of 5 patients proceeded to delivery by elective caesarean section at 38-39 weeks gestation. 1 of 5 patients is currently pregnant at 15 weeks gestation. Conclusion: Laparoscopic uterine cerclage remains a novel technique for women with recurrent pregnancy loss. Data from published literature is sparse and there are no randomised control trials comparing management options for women with recurrent pregnancy loss despite the use of a history indicated cervical cerclage. Despite our small numbers the audit data suggest this novel technique has a good safety profile and efficacy. This audit supports the continued use of this technique in our unit in women with refractory mid-trimester losses.
728 Real Time Haptic Feedback in Endoscopy: The Proof of Concept Vleugels MPH,1 Nieboer B.2 1Ob/Gyn, Riverland Hospital Tiel, Tiel, Gelderland, Netherlands; 2Ob/Gyn, University Hospital Radboud Nijmegen, Nijmegen, Gelderland, Netherlands Study objectives: Laparoscopic Instruments, conventional and robotic, lack real time haptic feedback due to the high friction of the instruments and low accuracy; no tissue information and no control of the gripping
S209
Details of cases SI No
Case details
Procedure performed
Estimated blood loss (mls)
1 2 3
Ruptured left tubal ectopic pregnancy Ruptured right tubal ectopic Heterotropic pregnancy with ruptured right isthmic pregnancy Ovarian pregnancy post recent salpingectomy for previous ectopic pregnancy Ruptured isthmic pregnancy
Laparoscopic left salpingectomy Laparoscopic right salpingectomy Laparoscopic right salpingectomy
2500 3000 2000
Laparoscopic wedge resection of ovarian pregnancy Laparoscopic right salpingectomy
1000
1 day
4200
1 day
4 5
723 Abdominal Pregnancy – A Constant Location? A Case Report of an Omental Viable Pregnancy and Review of Literature Sharon A, Anderman S, Raviv S, Groisman G, Hallak M. Ob/Gyn, Hillel Yaffe, Hadera, Israel Study Objective: To report the first rare case of a viable omental pregnancy. Design: Case report. Setting: Department of Obstetrics and Gynecology of a university teaching hospital. Patients: A 37 years old woman. Intervention: Two laparoscopies. Measurements and Main Results: Main outcome measure: A first negative laparoscopy followed by a successful partial omentectomy in a second laparoscopy. Result: A 37 years old woman presented with mild vaginal bleeding, delay in menstruation and a positive BHCG. Via transvaginal ultrasound (TVS), a viable fetus was demonstrated on the left side. A laparoscopy was performed which showed normal both tubes and no sign of ectopic pregnancy. The tubes were removed together with a uterine curettage, while the histology thereafter, was negative. The next day TVS didn’t show the ectopic pregnancy any more. Four days later a sudden lower abdominal pain, hemoperitoneum, an ectopic pregnancy on the right side, and decreased in the hemoglobin were presented. The patient was rushed to operating room for a second laparoscopy, in which an omental ectopic pregnancy adhered to the right side was seen. Partial omentectomy was the treatment which ended the interesting story. This is the first documented case of omental pregnancy which firstly diagnosed with cardiac activity. Conclusion: An abdominal ectopic pregnancy, especially at the omentum, is a rare condition and difficult for diagnosis. A high level of suspicion should be taken in the presence of a negative laparoscopy.
724 Correlation Between the Number of Previous Pelvic Surgeries and Surgical Complications in Patients Undergoing Laparoscopic Hysterectomy Basurto-Diaz D,1 Flores-Mendoza H,1 Hernandez-Nieto CA,1 Garcia-Rodriguez LF.2 1Programa Multicentrico de Residencias Medicas, Tecnologico de Monterrey, Monterrey, Nuevo Leon, Mexico; 2Obstetrics and Gynecology, Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado de Nuevo Leon, Monterrey, Nuevo Leon, Mexico Study Objective: To analyze if a correlation exists between uterine size defined by final pathology-piece weight and the existence of surgical complications in women who underwent type VII total laparoscopic hysterectomy (LH). Design: A case-controlled, retrospective analysis. Continuous variables were expressed as means and standard deviations (SD) or medians and interquartile ranges (IQR), upon distribution analysis by AndersonDarling’s normality test. Statistical analysis to determine correlation
Blood obtained through salvage (mls) 1500 1300 1100
Duration of postoperative stay 1 day 2 days 3
between binary and quantitative variables was done with a binary logistic regression, establishing a 95% confidence interval (CI) and a p-value at \0.05. Setting: TECSalud healthcare system in Monterrey, northeastern Mexico. Patients: 235 consecutive patients undergoing type VII total LH performed from January 2008 through December 2014. Measurements and Main Results: Median patient age was 45 years (41-49 IQR) with a median 25.39 body mass index (21.4-28 IQR), a median history of pelvic surgeries of 2 (1-3 IQR). Median surgical time was 140 minutes (120-170 IQR) with a median 100 milliliters (50-300 IQR) of blood loss and a median in-hospital stay of 3 days (2-3 IQR). 14 or 6.6% or patients presented surgical complications, this group had a mean previous pelvic surgery history of 1.79 surgeries (1.37 SD) with a mean 176 minutes (50.3 SD) of surgical time. Binary logistic regression showed no evidence of statistical significant correlation between uterine weight and surgical complications (CI -0.463-0.265; p= 0.594). Conclusion: There is insufficient statistical evidence to determine that a correlation exists between the number of previous pelvic surgeries and the presence of surgical complications. Therefore, type VII total LH seems as a feasible and safe surgical procedure, resulting in a short hospital stay, with minimal blood loss, minimal operating time, and a low complication rate regardless of uterine weight.
725 Retrospective Analysis of 225 Cases Between Ligation of Uterine Arteries and Suturing of Uterine Vessels and Cervical Stump Ligation in Laparoscopic Supracervical Hysterectomy(LSH) Mun ST. Dept. of Ob/Gyn, Soon Chun Hyang University Hospital, Cheon An-si, Chung Nam, Republic of Korea Study Objective: To compare the efficacy and safety among three methods such as ligation of uterine vessels and suturing of uterine vessel and cervical stump ligation in LSH. Design: Retrospective analysis of 225 consecutive cases of LSH. Setting: University Hospital. Patients: 225 women (ages 33-53 yrs) undergoing Laparoscopic supracervical hysterectomy. 68 women was uterine vessel ligation group, 58 women was uterine vessel suturing group, 99 women cervical stump ligation. Intervention: Charts were reviewed to determine post-operative complications and surgical values. A comparison was made among three groups in post-operative hemoglobin, and hematocrits changes, operation time, blood loss during operation, post-operative drainage volume (n=225). Measurements and Main Results: There were no statistically significant difference among three groups in terms of age, indication for surgery, uterine size, body mass index, parity. There were significant difference in the average time of the procedure among three groups (stump ligation vs uterine vessel ligation vs uterine vessel suturing), 91.5min vs 69.0min vs 71 min (p\0.05). There were significant differences in blood loss, 145.4 ml vs 107.0ml vs 99 ml (p\0.05), change in hemoglobin, 1.52 vs 1.15 vs 1.11 (p\0.05) and hematocrit, 5.16 vs 3.78 vs 3.57 (p\0.05).
S210
Abstracts / Journal of Minimally Invasive Gynecology 22 (2015) S1–S253
stump ligation
Measurements and Main Results: There were 366 procedures coded as diagnostic laparoscopy and/or excision of peritoneal tissue performed during the study period. Of these, 55 were excluded for intrauterine device removal, hysterectomy or surgery only for bilateral tubal ligation. Of the remaining 311 cases, 149 were performed prior to fellowship trained MIGS surgeons joining the academic practice in January 2012. After the incident date, 162 cases were performed. Of the 149 procedures before the addition of the fellowship trained surgeons, none of the patients had intraoperative placement of LNG-IUDs. Following the addition of two MIGS trained surgeons, 21 LNG-IUDs were placed at the time of surgical treatment. The increase in procedures including concomitant intraoperative LNG-IUD placement after the incident date was statistically significant (p\0.0001). Conclusion: In our study there was a positive correlation between the faculty addition of MIGS trained surgeons and the incidence of intraoperative LNG-IUD placement. Practice patterns and physician influence amongst groups with fellowship-trained providers may provide additional insight to benign gynecologic disease management. Additional research is needed to determine if the LNG-IUD is an effective accompaniment to laparoscopic surgery and an effective postoperative treatment of diseases such as endometriosis and chronic pelvic pain.
Uterine vessel suture
727 Laparoscopic Uterine Cerclage: An Audit of Safety and Reproductive Outcomes Ma KKY, Edi-Osagie E. Gynaecology, St. Mary’s Hospital, Manchester, Greater Manchester, United Kingdom
Conclusion: Ligation of Uterine vessels and suturing of uterine vessels were safe and effective methods than ligation of stump in LSH.
726 Impact of Minimally Invasive Gynecologic Surgery Fellowship Training on Concomitant Levonorgestrel-Releasing Intrauterine Device Placement at the Time of Laparoscopic Surgery Vu C, Hernly E, Carey E, Swan K. University of Kansas Medical Center, Kansas City, Kansas Study Objective: To determine if training in Minimally Invasive Gynecologic Surgery (MIGS) is associated with an increased frequency of intraoperative levonorgestrel-releasing intrauterine device (LNG-IUD) placement for postoperative management of pelvic pain and endometriosis. Design: Retrospective chart review. Setting: University of Kansas Medical Center (KUMC). Patients: Pre-menopausal women age 18-50 years who underwent outpatient diagnostic laparoscopy and/or excision of peritoneal tissue from October 1, 2008 to March 31, 2015; 366 patients underwent surgery during this time period. Intervention: None
Study Objective: To determine the safety and efficacy of all cases of laparoscopic uterine cerclage performed in a tertiary referral centre in the last 5 years. Design: Retrospective clinical audit against National Institute of Clinical Excellence guidelines. Setting: Tertiary referral centre and university teaching hospital. Patients: All patients who underwent laparoscopic uterine cerclage from May 2010 to May 2014. Intervention: Laparoscopic insertion of uterine cerclage Measurements and Main Results: A total of five cases were identified. 100% of patients presented with a history of recurrent pregnancy loss or extreme premature labour (\26 weeks) despite the use of a prophylactic cervical cerclage. No intra-operative complications were noted. Mean intra-operative blood loss was 100ml, mean operating time was 92 minutes (range 68-121 min), no post-operative complications or readmissions was noted. 5 of 5 patients proceeded to spontanous conception. 4 of 5 patients proceeded to delivery by elective caesarean section at 38-39 weeks gestation. 1 of 5 patients is currently pregnant at 15 weeks gestation. Conclusion: Laparoscopic uterine cerclage remains a novel technique for women with recurrent pregnancy loss. Data from published literature is sparse and there are no randomised control trials comparing management options for women with recurrent pregnancy loss despite the use of a history indicated cervical cerclage. Despite our small numbers the audit data suggest this novel technique has a good safety profile and efficacy. This audit supports the continued use of this technique in our unit in women with refractory mid-trimester losses.
728 Real Time Haptic Feedback in Endoscopy: The Proof of Concept Vleugels MPH,1 Nieboer B.2 1Ob/Gyn, Riverland Hospital Tiel, Tiel, Gelderland, Netherlands; 2Ob/Gyn, University Hospital Radboud Nijmegen, Nijmegen, Gelderland, Netherlands Study objectives: Laparoscopic Instruments, conventional and robotic, lack real time haptic feedback due to the high friction of the instruments and low accuracy; no tissue information and no control of the gripping