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Successful Laparoscopic Resection of Noncommunicating Rudimentary Uterine Horn and Bilateral Ovarian Endometrioma with Severe Adhesion
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Abstracts / Journal of Minimally Invasive Gynecology 17 (2010) S152–S177
Design: This paper uses slides and movies to present our technique of performing TLH. The delineator consists of a rotating lip (ROOLIP) which rotates on a uterine manipulator. The design of the ROOLIP delineator lifts up tissue for dissection, in contrast with other delineators, which require the surgeon to dissect down to the delineator. Setting: Operations were performed in a major private teaching hospital in Perth, Australia. These instruments have been used to perform over 2000 TLH cases. Patients: Private patients with informed financial and operative consent. Intervention: No conversion to open hysterectomy was required using these instruments in patients chosen for TLH. Measurements and Main Results: All TLH operations were successfully concluded using these instruments. Conclusion: Use of the ROOLIP manipulator lifts the uterine arteries for identification and minimises bladder, ureteric and rectal injuries.
Setting: Southeastern advanced laparoscopic gynecologic practice. Patients: Two hundred and twenty six patients (23-74 years old) who presented with an indication for total hysterectomy. Intervention: Total laparoscopic hysterectomy performed using the McCarus technique. Measurements and Main Results: Charts of 226 consecutive patients who underwent total laparoscopic hysterectomy via the McCarus technique from January 2008 through December 2009 were reviewed for any complications during the 12 week postoperative period. There were 6 (2.7%) patients with vaginal cuff dehiscence. Two (0.9%) patients required reoperation for abscess drainage and two (0.9%) required reoperation for bleeding. Minor complications included 14 (6.2%) urinary tract infections, 10 (4.4%) with granulation tissue, 5 (2.2%) trocar site cellulites, 4 (1.8%) cases of bacterial vaginosis, and 2 (1.7%) cases of postoperative fever. Conclusion: The McCarus technique is a safe method for performing total laparoscopic hysterectomy.
569 What Is the Learning Curve for Single-Port Access LaparoscopicAssisted Vaginal Hysterectomy? Song T, Kim T-J, Park HS, Kim M-K, Lee Y-Y, Choi CH, Lee J-W, Kim B-G, Bae D-S. Department of Obstetrics & Gynecology, Samsung Medical Center, Seoul, Republic of Korea Study Objective: Single-port access (SPA) surgery is a rapidly advancing technique in laparoscopic surgery. Currently, there is limited evidence on the learning curve and complications of performing SPA-laparoscopicassisted vaginal hysterectomies (LAVHs). Design: A prospective, single-center study (Canadian Task Force classification III). Setting: University hospital. Patients: One hundred patients who initially planned to undergo a SPALAVH for benign indications between May 2008 and October 2009. Intervention: SPA-LAVH procedures were performed on all patients who would have otherwise been offered a conventional LAVH. Data that were prospectively collected included total operative time, demographic information, and peri-operative complications. We analyzed the learning curve, defined as the number of cases required to stabilize the operative time in performing the SPA procedure. Measurements and Main Results: One hundred patients were treated during a 18-month period with SPA-LAVH. The operative time decreased from a median of 133.0 minutes (interquatile range, 107.5-162.5) in the first 25 cases to a median of 97.0 minutes (interquatile range, 78.0-117.5) for the last 25 cases. The operative time became consistent at approximately 105 minutes after 50 cases. This trend revealed a significant learning curve in the operative time (p=0.005). Most SPA-LAVHs were successful, but additional ports were needed in 5 patients because of pelvic adhesions (n=3) and large uterine size (n=2). Insertion of additional trocars was required most often in the first 25 cases. There were 3 cases with post-operative complications (hemorrhage, 1; vesicovaginal fistula, 1; and cuff abscess, 1), who were managed without sequelae. We encountered no umbilical complications with the single port at a median follow-up of 6.2 months (range, 1-21 months). Conclusion: Based on learning curve analysis, the SPA-LAVH procedure reached a plateau with respect to operative time after 50 cases without increasing complications.
571 A Prospective Comparison of Single Post Access Hysterectomy and Laparoscopic Hysterectomy in Women with Benign Uterine Disease Vora S, Robinson J. Obstetrics and Gynecology, George Washington University Medical Center, Washington, District of Columbia Study Objective: Background: Single port access (SPA) surgery is now generating increased interest due to improvements in instrumentation. Because it is one incision compared to three to four incisions, SPA has produced cosmetic results that are superior to laparoscopic procedures. Limited data from controlled trials are available to compare the two procedures in terms of morbidity with hysterectomy. The main objectives of this study are to compare laparoscopic hysterectomy vs SPA and determine which is superior in terms of intraoperative, immediate post operative, and short term post operative outcomes. Design: 1. patients will be consented for SPA or LH if the reason for hysterectomy is due to benign findings they meet the inclusion criteria 2. schedule for surgery 3. collect intraoperative data including operating time, morcellation time, uterus weight, EBL, and intraoperative complications. 4. collect post operative data by giving patients a post operative questionnaire and by calling patients 48 hours after surgery to collect data 5. analyze data. Setting: GWU medical center with 1-2 attending physicians conducting the surgeries with the aid of residents. Patients: Inclusion criteria: women, benign uterine disease, size of uterus less than or equal to 14cm in length and less than 8 cm wide by transvaginal sono, less than or equal to one cesarean or pelvic laparotomy. Exclusion criteria: prior laparoscopic or abdominal myomectomy, BMI greater than 40, current pelvic inflammatory disease, unstable for laparoscopy, pregnancy, known pelvic or gyn cancer. Intervention: 15 patients will undergo SPA hysterectomy and 15 patients will undergo laparoscopic hysterectomy. Measurements and Main Results: Preliminary data will be discussed. Conclusion: Preliminary data will be discussed.
570 Complication Rates in Total Laparoscopic Hysterectomies Performed Using the McCarus Technique Swan KA, Spytek SJ, McCarus SD, Kim J, Caceres A. Center for Specialized Gynecology, Florida Hospital Celebration Health, Celebration, Florida Study Objective: To assess the types and frequency of complications following total laparoscopic hysterectomy performed using the McCarus technique. Design: Retrospective analysis of complications following 226 consecutive cases of total laparoscopic hysterectomy performed using the McCarus technique.
572 Successful Laparoscopic Resection of Noncommunicating Rudimentary Uterine Horn and Bilateral Ovarian Endometrioma with Severe Adhesion Yamasaki H, Fukuda M, Matsuo T, Oki T, Douchi T. Department of Obstetrics & Gynecology, Kagoshima University, Kagoshima, Japan Study Objective: To perform successful laparoscopic removal of rudimentary uterine horn and ovarian endometrioma without complications. Design: A case report.
Abstracts / Journal of Minimally Invasive Gynecology 17 (2010) S152–S177
S167
Setting: Kagoshima University Hospital, Kagoshima, Japan. Patients: A 27-year-old female, nulliparous woman, was referred to our clinic for the treatment of progressive dysmenorrhea. Hysterosalpingography (HSG) revealed a right uterine horn with a patent tube. Magnetic resonance imaging (MRI) revealed a right unicornuate uterus continuing to the uterine cervix and vagina, and a rudimentary left uterine horn. Intervention: After full informed consent, laparoscipic removal of rudimentary uterine horn and ovarian endometrioma was chosen. Laparoscopy revealed a noncommunicating left uterine horn and bilateral ovarian endometrioma with severe adhesion to neighboring organs. The ovarian endometrioma and rudimentary horn were excised and removed laparoscopically without complications. Measurements and Main Results: The surgical duration was 298 minutes and the volume of blood loss during operation was 290 mL. Postoperative course was uneventful, and she was discharged day 7 postoperatively. There is no evidence of the recurrence of endometriosis one year after operation. Conclusion: Our result suggests that laparoscopic surgery is an effective treatment for dysmenorrhea associated with noncommunicating rudimentary uterine horn. Moreover, HSG and MRI are useful diagnostic modality of this uterine malformation. Early ligation of uterine artery reduces intraoparetive blood loss by decreasing uterine blood flow. We stress that noncommunicating rudimentary uterine horn can be treated by laparoscopic resection.
573 Laparoscopic Assisted Ultraminilaparotomy Supracervical Hysterectomy Assisted by Self-Retaining Elastic Wound Retractor Yen Y-K, Liu W-M, Tzeng C-R. Department of Obstetrics and Gynecology, Taipei Medical University Hospital and Taipei Medical University, Taipei, Taiwan Study Objective: To verify the efficacy and safety of laparoscopic assisted ultraminilaparotomy supracervical hysterectomy assisted by self-retaining elastic wound retractor. Design: Retrospective study (Canadian Task Force classification II-3). Setting: Private hospital, department of obstetrics and gynecology. Patients: 63 women, age 34 to 66 years, with benign uterine pathology or preinvasive neoplasia. Intervention: Laparoscopic assisted ultraminilaparotomy supracervical hysterectomy assisted by self-retaining elastic wound retractor. Measurements and Main Results: The mean operative times was 65 +/29.5 minutes (95% CI 59.1-68.9). There were no intraoperative complications. There was no need to change to explore laparotomy. 5 patients developed complications during the immediate postoperative period (fever in 2, hematoma of the surgical wound in 1, sub-aponeurotic seroma in 2, pubic edema in 1). During the late postoperative period, a vaginal cuff dehiscence was reported. Mean postoperative hospital stay was 2.6 +/- 0.3 days (95% CI 2.1-2.5). Conclusion: Laparoscopic assisted ultraminilaparotomy supracervical hysterectomy assisted by self-retaining elastic wound retractor is a safe and effective minimally invasive procedure. Also, it appears to be a good alternative to laparoscopic supracervical hysterectomy for institutions that do not have the required expensive equipment or for gynecologists who do not have excellent laparoscopic suture technique. POSTER SESSION–NEW INSTRUMENTATION
574 Description of the Modified Technique to Improving Success Rate of Applying Seprafilm Laparoscopically Chuang Y-C,1 Chen M-J,2 Ho SY,1 Kan Y-Y,1 Chang P-T.1 1OBS&GYN, Fooyin University Hospital, Pingtung, Taiwan; 2OBS&GYN, Veterans General Hospital Taichung, Taichung, Taiwan Study Objective: To describe the modified surgical procedure of applying anti-adhesion barrier –seprafilm laparoscopically.
Design: Retrospective analysis by videos and pictures showing laparoscopic procedure of application of seprafilm. Setting: University Hospital. Patients: Women receiving fertility-sparing laparoscopic surgeries (myomectomy, ovarian chocolate cyst or dermid cyst enucleation and tuboplasty) modified technique which described by Chuang et al (Fertility and Sterility 2008; 90:1959-63). Intervention: Roll two layers of pieces of seprafilm (figure 1) with plastic bag into a roll and delivered it through 10mm trocar (figure 2) and use irrigation tube to moistened the seprafilm and cover the irregular postoperative rough surface of organ. Changing the patients’ position after application of seprafilm with Reverse Trendelenburg position to check whether the seprafilm remain on target rough surface to act as a physical barrier. Measurements and Main Results: Pictures and video showing that the seprafilm remain on the post operative rough surface after change the patient position as a physical barrier. A second look laparoscopy showing the seprafilm turn into gel-like and remain between intestine and posterior rough surface of uterus on the 4th day post-myomectomy. A Cesarean section revealed previous post-dermoid cyst enucleation ovary had only minimal adhesion compare with De-Novo adhesion formation over the un-operated contrary ovary. Conclusion: It is feasible and easier to apply the seprafilm laparoscopically by the modified technique.
Abstracts / Journal of Minimally Invasive Gynecology 17 (2010) S152–S177
Design: This paper uses slides and movies to present our technique of performing TLH. The delineator consists of a rotating lip (ROOLIP) which rotates on a uterine manipulator. The design of the ROOLIP delineator lifts up tissue for dissection, in contrast with other delineators, which require the surgeon to dissect down to the delineator. Setting: Operations were performed in a major private teaching hospital in Perth, Australia. These instruments have been used to perform over 2000 TLH cases. Patients: Private patients with informed financial and operative consent. Intervention: No conversion to open hysterectomy was required using these instruments in patients chosen for TLH. Measurements and Main Results: All TLH operations were successfully concluded using these instruments. Conclusion: Use of the ROOLIP manipulator lifts the uterine arteries for identification and minimises bladder, ureteric and rectal injuries.
Setting: Southeastern advanced laparoscopic gynecologic practice. Patients: Two hundred and twenty six patients (23-74 years old) who presented with an indication for total hysterectomy. Intervention: Total laparoscopic hysterectomy performed using the McCarus technique. Measurements and Main Results: Charts of 226 consecutive patients who underwent total laparoscopic hysterectomy via the McCarus technique from January 2008 through December 2009 were reviewed for any complications during the 12 week postoperative period. There were 6 (2.7%) patients with vaginal cuff dehiscence. Two (0.9%) patients required reoperation for abscess drainage and two (0.9%) required reoperation for bleeding. Minor complications included 14 (6.2%) urinary tract infections, 10 (4.4%) with granulation tissue, 5 (2.2%) trocar site cellulites, 4 (1.8%) cases of bacterial vaginosis, and 2 (1.7%) cases of postoperative fever. Conclusion: The McCarus technique is a safe method for performing total laparoscopic hysterectomy.
569 What Is the Learning Curve for Single-Port Access LaparoscopicAssisted Vaginal Hysterectomy? Song T, Kim T-J, Park HS, Kim M-K, Lee Y-Y, Choi CH, Lee J-W, Kim B-G, Bae D-S. Department of Obstetrics & Gynecology, Samsung Medical Center, Seoul, Republic of Korea Study Objective: Single-port access (SPA) surgery is a rapidly advancing technique in laparoscopic surgery. Currently, there is limited evidence on the learning curve and complications of performing SPA-laparoscopicassisted vaginal hysterectomies (LAVHs). Design: A prospective, single-center study (Canadian Task Force classification III). Setting: University hospital. Patients: One hundred patients who initially planned to undergo a SPALAVH for benign indications between May 2008 and October 2009. Intervention: SPA-LAVH procedures were performed on all patients who would have otherwise been offered a conventional LAVH. Data that were prospectively collected included total operative time, demographic information, and peri-operative complications. We analyzed the learning curve, defined as the number of cases required to stabilize the operative time in performing the SPA procedure. Measurements and Main Results: One hundred patients were treated during a 18-month period with SPA-LAVH. The operative time decreased from a median of 133.0 minutes (interquatile range, 107.5-162.5) in the first 25 cases to a median of 97.0 minutes (interquatile range, 78.0-117.5) for the last 25 cases. The operative time became consistent at approximately 105 minutes after 50 cases. This trend revealed a significant learning curve in the operative time (p=0.005). Most SPA-LAVHs were successful, but additional ports were needed in 5 patients because of pelvic adhesions (n=3) and large uterine size (n=2). Insertion of additional trocars was required most often in the first 25 cases. There were 3 cases with post-operative complications (hemorrhage, 1; vesicovaginal fistula, 1; and cuff abscess, 1), who were managed without sequelae. We encountered no umbilical complications with the single port at a median follow-up of 6.2 months (range, 1-21 months). Conclusion: Based on learning curve analysis, the SPA-LAVH procedure reached a plateau with respect to operative time after 50 cases without increasing complications.
571 A Prospective Comparison of Single Post Access Hysterectomy and Laparoscopic Hysterectomy in Women with Benign Uterine Disease Vora S, Robinson J. Obstetrics and Gynecology, George Washington University Medical Center, Washington, District of Columbia Study Objective: Background: Single port access (SPA) surgery is now generating increased interest due to improvements in instrumentation. Because it is one incision compared to three to four incisions, SPA has produced cosmetic results that are superior to laparoscopic procedures. Limited data from controlled trials are available to compare the two procedures in terms of morbidity with hysterectomy. The main objectives of this study are to compare laparoscopic hysterectomy vs SPA and determine which is superior in terms of intraoperative, immediate post operative, and short term post operative outcomes. Design: 1. patients will be consented for SPA or LH if the reason for hysterectomy is due to benign findings they meet the inclusion criteria 2. schedule for surgery 3. collect intraoperative data including operating time, morcellation time, uterus weight, EBL, and intraoperative complications. 4. collect post operative data by giving patients a post operative questionnaire and by calling patients 48 hours after surgery to collect data 5. analyze data. Setting: GWU medical center with 1-2 attending physicians conducting the surgeries with the aid of residents. Patients: Inclusion criteria: women, benign uterine disease, size of uterus less than or equal to 14cm in length and less than 8 cm wide by transvaginal sono, less than or equal to one cesarean or pelvic laparotomy. Exclusion criteria: prior laparoscopic or abdominal myomectomy, BMI greater than 40, current pelvic inflammatory disease, unstable for laparoscopy, pregnancy, known pelvic or gyn cancer. Intervention: 15 patients will undergo SPA hysterectomy and 15 patients will undergo laparoscopic hysterectomy. Measurements and Main Results: Preliminary data will be discussed. Conclusion: Preliminary data will be discussed.
570 Complication Rates in Total Laparoscopic Hysterectomies Performed Using the McCarus Technique Swan KA, Spytek SJ, McCarus SD, Kim J, Caceres A. Center for Specialized Gynecology, Florida Hospital Celebration Health, Celebration, Florida Study Objective: To assess the types and frequency of complications following total laparoscopic hysterectomy performed using the McCarus technique. Design: Retrospective analysis of complications following 226 consecutive cases of total laparoscopic hysterectomy performed using the McCarus technique.
572 Successful Laparoscopic Resection of Noncommunicating Rudimentary Uterine Horn and Bilateral Ovarian Endometrioma with Severe Adhesion Yamasaki H, Fukuda M, Matsuo T, Oki T, Douchi T. Department of Obstetrics & Gynecology, Kagoshima University, Kagoshima, Japan Study Objective: To perform successful laparoscopic removal of rudimentary uterine horn and ovarian endometrioma without complications. Design: A case report.
Abstracts / Journal of Minimally Invasive Gynecology 17 (2010) S152–S177
S167
Setting: Kagoshima University Hospital, Kagoshima, Japan. Patients: A 27-year-old female, nulliparous woman, was referred to our clinic for the treatment of progressive dysmenorrhea. Hysterosalpingography (HSG) revealed a right uterine horn with a patent tube. Magnetic resonance imaging (MRI) revealed a right unicornuate uterus continuing to the uterine cervix and vagina, and a rudimentary left uterine horn. Intervention: After full informed consent, laparoscipic removal of rudimentary uterine horn and ovarian endometrioma was chosen. Laparoscopy revealed a noncommunicating left uterine horn and bilateral ovarian endometrioma with severe adhesion to neighboring organs. The ovarian endometrioma and rudimentary horn were excised and removed laparoscopically without complications. Measurements and Main Results: The surgical duration was 298 minutes and the volume of blood loss during operation was 290 mL. Postoperative course was uneventful, and she was discharged day 7 postoperatively. There is no evidence of the recurrence of endometriosis one year after operation. Conclusion: Our result suggests that laparoscopic surgery is an effective treatment for dysmenorrhea associated with noncommunicating rudimentary uterine horn. Moreover, HSG and MRI are useful diagnostic modality of this uterine malformation. Early ligation of uterine artery reduces intraoparetive blood loss by decreasing uterine blood flow. We stress that noncommunicating rudimentary uterine horn can be treated by laparoscopic resection.
573 Laparoscopic Assisted Ultraminilaparotomy Supracervical Hysterectomy Assisted by Self-Retaining Elastic Wound Retractor Yen Y-K, Liu W-M, Tzeng C-R. Department of Obstetrics and Gynecology, Taipei Medical University Hospital and Taipei Medical University, Taipei, Taiwan Study Objective: To verify the efficacy and safety of laparoscopic assisted ultraminilaparotomy supracervical hysterectomy assisted by self-retaining elastic wound retractor. Design: Retrospective study (Canadian Task Force classification II-3). Setting: Private hospital, department of obstetrics and gynecology. Patients: 63 women, age 34 to 66 years, with benign uterine pathology or preinvasive neoplasia. Intervention: Laparoscopic assisted ultraminilaparotomy supracervical hysterectomy assisted by self-retaining elastic wound retractor. Measurements and Main Results: The mean operative times was 65 +/29.5 minutes (95% CI 59.1-68.9). There were no intraoperative complications. There was no need to change to explore laparotomy. 5 patients developed complications during the immediate postoperative period (fever in 2, hematoma of the surgical wound in 1, sub-aponeurotic seroma in 2, pubic edema in 1). During the late postoperative period, a vaginal cuff dehiscence was reported. Mean postoperative hospital stay was 2.6 +/- 0.3 days (95% CI 2.1-2.5). Conclusion: Laparoscopic assisted ultraminilaparotomy supracervical hysterectomy assisted by self-retaining elastic wound retractor is a safe and effective minimally invasive procedure. Also, it appears to be a good alternative to laparoscopic supracervical hysterectomy for institutions that do not have the required expensive equipment or for gynecologists who do not have excellent laparoscopic suture technique. POSTER SESSION–NEW INSTRUMENTATION
574 Description of the Modified Technique to Improving Success Rate of Applying Seprafilm Laparoscopically Chuang Y-C,1 Chen M-J,2 Ho SY,1 Kan Y-Y,1 Chang P-T.1 1OBS&GYN, Fooyin University Hospital, Pingtung, Taiwan; 2OBS&GYN, Veterans General Hospital Taichung, Taichung, Taiwan Study Objective: To describe the modified surgical procedure of applying anti-adhesion barrier –seprafilm laparoscopically.
Design: Retrospective analysis by videos and pictures showing laparoscopic procedure of application of seprafilm. Setting: University Hospital. Patients: Women receiving fertility-sparing laparoscopic surgeries (myomectomy, ovarian chocolate cyst or dermid cyst enucleation and tuboplasty) modified technique which described by Chuang et al (Fertility and Sterility 2008; 90:1959-63). Intervention: Roll two layers of pieces of seprafilm (figure 1) with plastic bag into a roll and delivered it through 10mm trocar (figure 2) and use irrigation tube to moistened the seprafilm and cover the irregular postoperative rough surface of organ. Changing the patients’ position after application of seprafilm with Reverse Trendelenburg position to check whether the seprafilm remain on target rough surface to act as a physical barrier. Measurements and Main Results: Pictures and video showing that the seprafilm remain on the post operative rough surface after change the patient position as a physical barrier. A second look laparoscopy showing the seprafilm turn into gel-like and remain between intestine and posterior rough surface of uterus on the 4th day post-myomectomy. A Cesarean section revealed previous post-dermoid cyst enucleation ovary had only minimal adhesion compare with De-Novo adhesion formation over the un-operated contrary ovary. Conclusion: It is feasible and easier to apply the seprafilm laparoscopically by the modified technique.