Targeted Ultrasound in Endometriosis

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Abstracts / Journal of Minimally Invasive Gynecology 21 (2014) S191–S227

The patient is a 36-year-old with a history of a hysterectomy and a right salpingo-ophorectomy due to pelvic pain and endometriosis. The purpose of the procedure was to take down adhesions and removal of fallopian tube due to an adnexal cyst and pelvic pain. Adhesions from the omentum were encountered. These were dissected and taken down with the Ligasure 1637. The mobility and shape of the jaws aid in dissection of tissue in planes. This new device continues to have a very reliable sealing capability. In addition, the new aspects allow for better dissection of surgical planes. 672 Gynecology Asepsis Protocol Desai VB, Chatterjee S, Fan L. Ob/Gyn, Yale Medical School, New Haven, Connecticut Surgical site infections affect approximately 500,000 patients who undergo surgery in the United States, resulting in increased patient morbidity and mortality while costing hospitals $7.4 billion dollars annually. Many gynecological procedures are considered clean-contaminated as the sterile peritoneal cavity is exposed to endogenous microbial flora of the vagina. In addition to intravenous prophylactic antibiotic administration, surgical site antisepsis plays a major role in the prevention of SSIs. Several recent studies have established the benefits of chlorhexidine gluconate over povidone-iodine preparations; however there is limited data available regarding the optimal protocol for preoperative skin asepsis. Additionally, there is limited formalized teaching provided to trainees regarding the proper method of skin preparation. This educational video was produced for use in resident-training sessions, and will be a requirement for all attending gynecologists and OR staff who participate in gynecological procedures.

673 Innovative Surgical Simulation Exercises for Teaching Laparoscopy Using a Live Pig Model King CR,1 Lum D.2 1Ob/Gyn, Magee-Womens Hospital of UPMC, Pittsburgh, Pennsylvania; 2Ob/Gyn, Stanford University, Stanford, California Teaching laparoscopy is challenging in surgical residency programs secondary to the highly technical nature and steep learning curve. Live animal models closely simulate operating on live tissue, and allow learners to practice with various electrosurgical modalities. We demonstrate 3 laparoscopic exercises on a live pig model, which resemble a laparoscopic salpingectomy, excision of deeply penetrating endometriosis, and a hysterectomy. These exercises allow the learner to practice various surgical techniques and provide a strong foundation of surgical skills that translate to the operating room.

674 Lap Surgical Anatomy of Ureter and Its Application in Gynaecological Surgeries Puntambekar SP, Kumar S, Johi G, Hosamani G. Galaxy Care Laparoscopy Institute, Pune, Maharashtra, India Ureter is the organ most feared by the gynecologist. Majority of the procedures described in the books do not involve the exposure of ureters. Thus one gets used to not dissecting ureters. This practice is dangerous especially during difficult dissections or difficult abdominal/pelvic pathologies. The video depicts the actual ureteric anatomy and how its knowledge can be applied in day to day practice. Thus it shows the ureteric course, its blood supply and its anatomical relations to the surrounding structures. This video also demonstrates how to tackle difficult situations and key steps in ureteric dissections.Knowledge of ureteric anatomy will improve surgical results and also will alleviate fear of damage to the ureter.

675 Dissection of Hipogastric Plexus and Sacral Nerves on Unembalmed Female Cadaver Rius M,1 Vilanova J,2 Cayuela E,3 Carmona F.1 1Institut Clinic of Gynecology, Obstetrics and Neonatology, Hospital Clinic, Barcelona, Spain; 2Department of Gynecology, Obstetrics, Pediatrics and Anatomy, Faculty of Medicine, University of Barcelona, Barcelona, Spain; 3 Department of Gynecology and Obstetrics, Hospital General de l’Hospitalet, L’Hospitalet de Llobregat, Barcelona, Spain The identification of the hipogastric plexus during gynecological surgeries is sometimes quite a challenge. In the same way, some of the new gynecological surgical techniques work on the posterior part of the pelvic cavity, an area that has not been traditionally common to work on. In order to describe the anatomy of this area, we performed the dissection of hipogastric plexus and the sacral nerves on unembalmed female cadaver and we summarize it in this video.

676 Use of a 30 Degree Angled Hysteroscope Woods SM,1 Sale MT,2 Martin D.1 1Obstetrics and Gynecology, University of Tennessee, Memphis, Memphis, Tennessee; 2Obstetrics and Gynecology, University of New Mexico, Albuquerque, New Mexico The purpose of this video is to provide an introduction for the novice on how to use a 30 degree angled hysteroscope. We address two key concepts: understanding the angle of view and changing the angle of view. We achieve this by visually explaining the 30 degree eccentric center of the operative field and changing the angle of view with the use of movements of the hysteroscopic light cord. This introduction emphasizes orientation of the image.

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Poster Video: Endometriosis

Para-Ovarian Endomerioma in a Patient with a Congenital Uterine Anomaly Arendas K, Leyland NA. Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada Congenital uterine anomalies are a rare entity and are known to be associated with endometriosis. A 26 year-old woman with chronic pelvic pain was found to have a m€ullerian anomaly and a large recurrent endometrioma in an uncommon para-ovarian location. She underwent resection of the functional, non-communicating uterine horn, as well as excision of the endometrioma and pelvic endometriosis. This case illustrates several important points. First, surgical management of m€ullerian anomalies can range from simple to very complex depending on the type of anomaly and severity of endometriosis present. Therefore, pre-operative imaging and careful pre-operative planning is key to the success of the surgical procedure. Secondly, this case is an excellent example of the rapid recurrence of an unusually located endometrioma despite ‘‘excision’’ an identical cyst only months prior, illustrating the importance of the removal of all parts of cyst wall to reduce the risk of recurrence.

678 Targeted Ultrasound in Endometriosis Bougie O,1 Agarwal S,1 Fraser M,2 Singh SS.1 1Department of Obstetrics and Gynecology, The Ottawa Hospital, Ottawa, Ontario, Canada; 2 Department of Diagnostic Imaging, The Ottawa Hospital, Ottawa, Ontario, Canada This is an education video highlighting the use of targeted ultrasound in endometriosis The objectives of this presentation are:

Abstracts / Journal of Minimally Invasive Gynecology 21 (2014) S191–S227 1. to review the utility of ultrasound in diagnosis and preoperative planning in endometriosis 2. to provide a systematic approach to ultrasound for endometriosis 3. to demonstrate through case presentations, the use of targeted ultrasound in planning for surgical treatment of deep infiltrative endometriosis Endometriosis is a heterogenous disease that may present in many different ways. It is typically diagnosed on a clinical basis and the utility of imaging in diagnosis of endometriosis has been fairly limited, mainly to look for endometriomas. Recent evidence has shown that a targeted, ‘‘tenderness guided’’ ultrasound can diagnose endometriosis with a sensitivity and specificity approximating 90%. We present two cases of deep infiltrative endometriosis where a preoperative ultrasound was central in appropriate surgical planning and excellent outcome for the patient. 679 Laparoscopic Excision of Deep Rectovaginal Endometriosis Nodule Chamsy DJ, Lee TM. Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania The laparoscopic excision of a deep rectovaginal endometriosis nodule is a challenging procedure. The location of the nodule deep in the pelvic, limits exposure and access. The concomitant obliteration of the rectovaginal space makes the dissection tedious as surgical planes are distorted by the disease. Moreover, deep involvement of the rectal wall necessitates simultaneous bowel surgery. Rather than trying to penetrate an obliterated rectovaginal space to excise the vaginal and rectal components of the nodule separately and in a piece meal fashion, we illustrate a novel surgical technique which consists of resecting the rectovaginal nodule en block: we first perform a partial vaginectomy to separate the nodule from the vaginal canal. With the nodule attached to the rectum along with is vaginal portion, we perform a bowel resection to remove the rectovaginal nodule in one piece. We subsequently repair the bowel by end to end anastomosis. 680 A New Application for Barbed Suture: Repair of Cystotomy and Enterotomy Ecker AM, Lee TTM. Department of Obstetrics and Gynecology, Magee-Womens Hospital of UPMC, Pittsburgh, Pennsylvania

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laparoscopic resection of the deep infiltrating endometriosis of the ureter causing stricture and successful laparoscopic ureteroureteral reanastamosis using the same technique our practice has been applying for the past twenty years. Although this technique requires advanced laparoscopic skills the technique allows successful end to end ureteral reanastamosis in situations that previously required more extensive procedures via laparotomy. By applying the principles of laparoscopic microsurgery including adequate mobilization of the proximal and distal ureteral segments, a tension free reanastamosis, viable ureteral segments for reanastamosis, and six interrupted sutures tied in a tension free manner a patient can expect optimal outcomes at 3 months post surgery in a minimally invasive fashion. 682 Robotic Assisted Resection of Vesicovaginal Endometriosis Nodule Mahmoud MS, Apostol R, Nezhat F. Minimally Invasive Gynecology, Saint Luke’s Roosevelt Hospital, New York, New York In this video we present a case of deep infiltrative endometriosis consistent with an endometriosis nodule in the vesicovaginal area,which is resected using the laparoscopic robotic assisted approach. The details of the technique and procedure as well as anatomical considerations are reviewed during the course of the video presentation. 683 Safe Endoscopic Laser Excision and Vaporization of Peritoneal Endometriosis Nezhat C, Balassiano E, Nezhat A, Parsa MA, Nezhat C. Obstetrics and Gynecology, Stanford University Medical Center, Palo Alto, California Video-assisted laparoscopy is being used with increasing frequency in the treatment of endometriosis. However, endometriosis of sensitive areas such as the bowel, bladder, ureter and major vessels are often excluded from surgical intervention due to risk of injury. This is detrimental to the patient, as endometriosis should be treated thoroughly wherever encountered if possible. The use of CO2 laser and hydrodissection allows for safe surgical treatment of endometriosis and has several advantages, such as precision, minimal tissue damage and risk of thermal injury to adjacent structures. This is a video presentation of safe laser excision and vaporization of peritoneal endometriosis. 684

Barbed suture has been approved by the Food and Drug Administration (FDA) since 2004. Here, we show examples where a unidirectional barbed suture was used for closure of intentional cystotomy and enterotomy after resection of endometriotic nodules. Case #1: Two-layer closure of a cystotomy after removal of a 3cm bladder nodule Case #2: Two-layer closure of an enterotomy after removal of 2cm rectal nodule Key points when using barbed suture for mucosal closures include: the use of assistive devices such as a rectal probes and ureteral stents, placement of angle sutures, and creation of a tension free closure. We have found the barbed suture to be a facile means of closing mucosal defects and have had minimal to no complications as a result. It is our opinion that the barbed suture is a useful tool to consider when closing intentional mucosal defects. 681 Laparoscopic Resection of Deep Infiltrating Ureteral Endometriosis and Ureteral Reanastamosis Hadiashar M,1 Liu LA,2 Rich SJ,1 Liu CY.1 1University of Tennessee Health Science Center College of Medicine Chattanooga, Chattanooga, Tennessee; 2Lenox Hill Hospital, New York, New York Endometriosis of the ureter although uncommon can lead to stricture with subsequent hydroureter and hydronephrosis. This video demonstrates

Laparoscopic Excision of Retroperitoneal Pelvic Mass over Right Iliac Vessels Nezhat C, Balassiano E, Nezhat A. Obstetrics and Gynecology, Stanford University Medical Center, Palo Alto, California Extragenital endometriosis represents 10-15% of all endometriosis cases and is defined as the presence of endometrial glands and stroma outside of the uterine cavity and pelvis. Pain is the most common presenting symptom (76.5%) and cyclic pain is the second (41.2%). Endometriosis occurring around large pelvic vessels has been reported to cause pain, catamenial edema and DVT. Our literature review shows two cases of extragenital endometriosis compressing the iliac vessels. We are presenting a case of a 49 year old female with history of endometriosis who presented of worsening right-sided and lower extremity pain for two months. The endometriotic lesion was confirmed with CT scan and preoperative consultation with vascular surgery was obtained due to close proximity of the lesion to the iliac vessels. The laparoscopic removal of the pelvic mass is shown in this video. 685

Poster Video: Hysteroscopy, Endometrial Ablation and Sterilization

Uterine Septum Resection Ritch JMB, Yunker AC, Anderson TL. Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee