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Robotic Ureterolysis in the Surgical Management of Endometriosis
Abstracts / Journal of Minimally Invasive Gynecology 19 (2012) S151–S178 This video aims to provide the practicing gynecologist with a brief overview of some of the clinical uses of cystourethroscopy. 560
demonstrated to be effective as well, but requires a process that will facilitate success. With good surgical technique, laparoscopic hysterectomy is feasible and safe, regardless of uterine weight. We highlight 6 steps to managing the enlarged at laparoscopic hysterectomy. 1. 2. 3. 4. 5. 6.
Primer in Risk Reducing Adnexal Surgery Caceres A. Florida Hospital at Celebration Health, Celebration, Florida Review of risk reducing surgical algorithm among BRCA mutation carriers. Mutations in DNA mismatch repair genes, BRCA 1 and 2 are transmitted via autosomal dominance and can be involved in protein instability. Patients with these mutations have been identified to have increased susceptibility to developing breast and ovarian cancers throughout their lifetimes. Risk reducing surgical prophylaxis can help decrease the risk of developing these cancer among mutation carriers.
S173
Preoperative assessment and decision making Optimize visualization Early intraoperative assessment Mobilize ligaments and pedicles Secure uterine vessels proximally Morcellation and specimen removal
These 6 key steps can be carried out routinely when managing the enlarged uterus. With experience, these principles can allow the surgeon to proceed safely and confidently with laparoscopic hysterectomy.
564 561 A Minimally Invasive Surgical Approach for Management of a Recurrent Cesarean Scar Ectopic Pregnancy Dhanani M, Seibel B. Obstetrics and Gynecology, University of Florida, College of Medicine, Jacksonville, Florida A cesarean scar ectopic pregnancy is a rare form of ectopic pregnancy with devastating complications such as uterine rupture and intractable bleeding. Diagnosis and treatment can be challenging particularly in a patient who presents with a recurrence. We present here the case of a 25 year-old woman who presented with cesarean scar ectopic pregnancy for 2 consecutive pregnancies 11 months apart. The primary ectopic pregnancy was managed with multidose methotrexate but required surgical intervention with D&C for complete resolution. For the recurrent cesarean scar ectopic, total laparscopic hysterectomy was performed to facilitate extensive lysis of adhesions, a safe dissection of the gravid uterus, and removal of the recurrent ectopic cesarean scar pregnancy without extensive blood loss or complications. Given the safety and efficacy of laparoscopy in such cases, increasing the utility of this wellknown technique may provide optimal management.
562 Herlyn-Werner-Wunderlich Syndrome: A Case Report of a Variant Form & Novel Treatment Technique Kondrup JD. OB/GYN, Lourdes Hospital, Binghamton, New York Uterine malformations occur with an incidence of about 7 - 10%. Complex malformations are rare. Herlyn-Werner-Wunderlich Syndrome (HWW) describes a triad of: Uterine Didelphys, Saggital Vaginal Septum and Ipsilateral Renal agenesis. Patients present at a young age with increasing dysmenorrhea and partial hematocolpos. Treatment can be challenging due to working in the virginal vagina and preserving the hymenal ring. This is extremely important in cultures where surgical vaginal manipulation is prohibited and special permission is needed. This technique describes the use of vaginoscopy as a guide to the operative site while allowing for excellent visualization. This video shows a minimally invasive technique which spares the hymenal ring and maintains patency of the canal after the vaginal septum is incisied.
Operative Hysteroscopy with a Resectascope Scheib SA, Curlin H, Anderson TL. Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee This video was created to help standardize the teaching of operative hysterscopy to residents. This is portion of a larger hysteroscopy curriculum for residents. They have a baseline assessment of their hysteroscopy skills at the beginning of each gynecology block. This video, along with 2 other videos on ‘‘diagnostic hysteroscopy’’ and ‘‘fluid management and electosurgical principles in hysteroscopy’’ are observed by each resident on the gynecology team at the beginning of every gynecology block. They are then retested on their skills in the simulation lab and then in the operating room at the end of the block.
VIDEO POSTER: ENDOMETRIOSIS 565 A Useful Technique for Bilateral Salpingo-Oopherectomy with Retroperitoneal Ureteral Dissection Apostolis CA, DiSciullo AJ. Division of Urogynecology, Mount Auburn Hospital, Cambridge, Massachusetts The use of single port surgery has evolved significantly over the past 5 years and continues to do so with better access ports and instrumentation. Although still in its infancy, the utility and applicability of this minimally invasive method has yet to be determined. We present a case of a 67 y.o. female with a chronic history of intermittent abdominal pain and suspected intermittent ovarian torsion treated with a single port bilateral salpingooophorectomy. We present our technique for performing this procedure through a single umbilical incision using the Gelpoint single port system (Applied Medical, Rancho Santa Margarita, CA) as well as performing a retroperitoneal dissection to further isolate the infundibulopelvic ligament, ureter and vital vascular structures from injury. This video demonstrates the single port setup, pelvic anatomy and surgical maneuvers necessary to perform this procedure through a laparoscopic single port approach.
566 563 Approach to the Difficult Laparoscopic Hysterectomy: Enlarged Uterus Mehra N, Singh SS. Obstetrics & Gynecology, University of Ottawa/The Ottawa Hospital, Ottawa, Ontario, Canada Traditional teaching would suggest that the enlarged uterus is best managed with laparotomy. However, some series describe that a vaginal hysterectomy may be possible in expert hands. The laparoscopic approach has been
Robotic Ureterolysis in the Surgical Management of Endometriosis Dahlman M, Eisenstein D. Obstetrics, Gynecology, and Women’s Health, Henry Ford Hospital, Detroit, Michigan Because of its proximity to the gynecologic organs, the ureter is easily injured inadvertently during gynecologic surgery. When the anatomy is distorted by endometriosis, the chances of injury increase. We present an overview of ureterolysis in complex endometriosis surgery, both for the purposes of avoiding injury and for its usefulness in identifying other distorted anatomy. Two cases are presented, one in a patient desiring extirpative surgery and the other in a nullipara desiring future fertility.
demonstrated to be effective as well, but requires a process that will facilitate success. With good surgical technique, laparoscopic hysterectomy is feasible and safe, regardless of uterine weight. We highlight 6 steps to managing the enlarged at laparoscopic hysterectomy. 1. 2. 3. 4. 5. 6.
Primer in Risk Reducing Adnexal Surgery Caceres A. Florida Hospital at Celebration Health, Celebration, Florida Review of risk reducing surgical algorithm among BRCA mutation carriers. Mutations in DNA mismatch repair genes, BRCA 1 and 2 are transmitted via autosomal dominance and can be involved in protein instability. Patients with these mutations have been identified to have increased susceptibility to developing breast and ovarian cancers throughout their lifetimes. Risk reducing surgical prophylaxis can help decrease the risk of developing these cancer among mutation carriers.
S173
Preoperative assessment and decision making Optimize visualization Early intraoperative assessment Mobilize ligaments and pedicles Secure uterine vessels proximally Morcellation and specimen removal
These 6 key steps can be carried out routinely when managing the enlarged uterus. With experience, these principles can allow the surgeon to proceed safely and confidently with laparoscopic hysterectomy.
564 561 A Minimally Invasive Surgical Approach for Management of a Recurrent Cesarean Scar Ectopic Pregnancy Dhanani M, Seibel B. Obstetrics and Gynecology, University of Florida, College of Medicine, Jacksonville, Florida A cesarean scar ectopic pregnancy is a rare form of ectopic pregnancy with devastating complications such as uterine rupture and intractable bleeding. Diagnosis and treatment can be challenging particularly in a patient who presents with a recurrence. We present here the case of a 25 year-old woman who presented with cesarean scar ectopic pregnancy for 2 consecutive pregnancies 11 months apart. The primary ectopic pregnancy was managed with multidose methotrexate but required surgical intervention with D&C for complete resolution. For the recurrent cesarean scar ectopic, total laparscopic hysterectomy was performed to facilitate extensive lysis of adhesions, a safe dissection of the gravid uterus, and removal of the recurrent ectopic cesarean scar pregnancy without extensive blood loss or complications. Given the safety and efficacy of laparoscopy in such cases, increasing the utility of this wellknown technique may provide optimal management.
562 Herlyn-Werner-Wunderlich Syndrome: A Case Report of a Variant Form & Novel Treatment Technique Kondrup JD. OB/GYN, Lourdes Hospital, Binghamton, New York Uterine malformations occur with an incidence of about 7 - 10%. Complex malformations are rare. Herlyn-Werner-Wunderlich Syndrome (HWW) describes a triad of: Uterine Didelphys, Saggital Vaginal Septum and Ipsilateral Renal agenesis. Patients present at a young age with increasing dysmenorrhea and partial hematocolpos. Treatment can be challenging due to working in the virginal vagina and preserving the hymenal ring. This is extremely important in cultures where surgical vaginal manipulation is prohibited and special permission is needed. This technique describes the use of vaginoscopy as a guide to the operative site while allowing for excellent visualization. This video shows a minimally invasive technique which spares the hymenal ring and maintains patency of the canal after the vaginal septum is incisied.
Operative Hysteroscopy with a Resectascope Scheib SA, Curlin H, Anderson TL. Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee This video was created to help standardize the teaching of operative hysterscopy to residents. This is portion of a larger hysteroscopy curriculum for residents. They have a baseline assessment of their hysteroscopy skills at the beginning of each gynecology block. This video, along with 2 other videos on ‘‘diagnostic hysteroscopy’’ and ‘‘fluid management and electosurgical principles in hysteroscopy’’ are observed by each resident on the gynecology team at the beginning of every gynecology block. They are then retested on their skills in the simulation lab and then in the operating room at the end of the block.
VIDEO POSTER: ENDOMETRIOSIS 565 A Useful Technique for Bilateral Salpingo-Oopherectomy with Retroperitoneal Ureteral Dissection Apostolis CA, DiSciullo AJ. Division of Urogynecology, Mount Auburn Hospital, Cambridge, Massachusetts The use of single port surgery has evolved significantly over the past 5 years and continues to do so with better access ports and instrumentation. Although still in its infancy, the utility and applicability of this minimally invasive method has yet to be determined. We present a case of a 67 y.o. female with a chronic history of intermittent abdominal pain and suspected intermittent ovarian torsion treated with a single port bilateral salpingooophorectomy. We present our technique for performing this procedure through a single umbilical incision using the Gelpoint single port system (Applied Medical, Rancho Santa Margarita, CA) as well as performing a retroperitoneal dissection to further isolate the infundibulopelvic ligament, ureter and vital vascular structures from injury. This video demonstrates the single port setup, pelvic anatomy and surgical maneuvers necessary to perform this procedure through a laparoscopic single port approach.
566 563 Approach to the Difficult Laparoscopic Hysterectomy: Enlarged Uterus Mehra N, Singh SS. Obstetrics & Gynecology, University of Ottawa/The Ottawa Hospital, Ottawa, Ontario, Canada Traditional teaching would suggest that the enlarged uterus is best managed with laparotomy. However, some series describe that a vaginal hysterectomy may be possible in expert hands. The laparoscopic approach has been
Robotic Ureterolysis in the Surgical Management of Endometriosis Dahlman M, Eisenstein D. Obstetrics, Gynecology, and Women’s Health, Henry Ford Hospital, Detroit, Michigan Because of its proximity to the gynecologic organs, the ureter is easily injured inadvertently during gynecologic surgery. When the anatomy is distorted by endometriosis, the chances of injury increase. We present an overview of ureterolysis in complex endometriosis surgery, both for the purposes of avoiding injury and for its usefulness in identifying other distorted anatomy. Two cases are presented, one in a patient desiring extirpative surgery and the other in a nullipara desiring future fertility.