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Unexpected Diagnosis of Smooth Muscle Tumor of Uncertain Malignant Potential after Laparoscopic Uterine Morcellation
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Abstracts / Journal of Minimally Invasive Gynecology 20 (2013) S133–S181
Design: Retrospective chart review. Setting: University teaching hospital. Patients: Ninety-nine post-hysterectomy patients with adnexal mass. Intervention: Laparoscopic adenxal surgery. Measurements and Main Results: We reviewed patients’ clinical chart and operation records. The median age of the patients and BMI were 51 (34-80) years and 24.3 (18.1-36.0) kg/m2. The median values of operating time, change of the hemoglobin concentration, return of bowel activity, and hospital stay were 111 (35-470) min, 1.9 (0-5.1) g/dL, 32 (14-96) hours and 5 (2-36) days, respectively. The final histopathological results showed simple cyst (31.2%), mucinous cystadenoma (24.7%) and serous cystadenoma (16.1%) from the ovary and paratubal cyst (17.2%) and hydrosalpinx (16.1%) from the tube. Five out of 93 cases from ovary were confirmed ovarian malignancy. There were 10 cases of intraoperative and 7 cases of postoperative complications. There were no conversions to laparotomy. Conclusion: Concomitant bilateral salpingectomy in hysterectomy is feasible and efficient and it can be offered to eradicate the chance of unnecessary additional surgery resulting from tubal causes.
491 Combined Use of Vasopressin and Uterine Artery Ligation for Myomectomy in Large Uteri at Limited Resource Setting Magdum AA, Padiyath HR, Puthiyidom A, Trehan N. Obstetrics and Gynecology, Sunrise Hospital, Ernakulam, Kerala, India Study Objective: Prolonged procedure and excessive blood loss are main concerns during laparoscopic myomectomy especially for large uterine fibroids. Various methods are tried for hemostasis. We share our experience of combined intra-operative use of vasopressin and uterine artery ligation (performed after myomectomy and before closure of myoma bed) for hemostasis during laparoscopic myomectomy for large fibroids in limited resource center with an aim to evaluate safety and efficacy. Design: This is a retrospective analysis of women who have undergone laparoscopic myomectomy at a center with limited resources. Setting: Secondary level care center with limited resources. Patients: All women with large uterine size (24-30 weeks) who have undergone laparoscopic myomectomy during June 2011 till December 2011 were included in this study. Intervention: In study group women underwent vasopressin injection followed by myomectomy then uterine artery ligation at its origin before closure of myoma bed. In control group women underwent laparoscopic myomectomy with vasopressin alone or uterine artery ligation. In control group, uterine artery ligation was done before myomectomy. Measurements and Main Results: We analyzed and compared the parameters like size of uterus, parity, difficulty in performing uterine artery ligation, need for intra-operative and postoperative blood transfusion, length of hospital stay and intra-operative complications in study and the control group. We had 32 women in study group and 54 women in control group. The need for blood transfusion (intra and postoperative period) was significantly less in study group (nil) compared with control group (12.9%). The length of hospital stay (3 or more days) was lesser in study group compared with control group (nil v/s 12.9%). Uterine artery ligation was difficult in few of the cases from control group but in none from study group. Conclusion: During laparoscopic myomectomy for large uteri, combined use of vasopressin and uterine artery ligation before myomectomy bed closure is very useful method for hemostasis especially in limited resource settings. 492 Analysis of Neonatal Outcomes in Women after Cerclage Placement Manoucheri E, Cohen SL, Hill-Lydecker C, Einarsson JI. Brigham & Women’s Hospital, Boston, Massachusetts
Study Objective: To analyze the livebirth rate and neonatal outcomes following laparoscopic or abdominal cerclage placement. Design: Retrospective follow-up study of 37 women who had laparoscopic cerclage and 16 who had abdominal cerclages placed. Setting: University teaching hospital. Patients: 37 women who had laparoscopic cerclage and 16 who had abdominal cerclage placed. Measurements and Main Results: Of 37 patients who underwent laparoscopic cerclage placement, 26 became pregnant while 13 of the 16 women who had abdominal cerclages became pregnant (age, BMI, and gravidity adjusted p-value=0.97). Of those that became pregnant, 69% (18/ 26) who had laparoscopic cerclages had a livebirth compared with 85% (11/13) who had abdominal cerclages, adjusted p=0.68. Mean gestational age at time of delivery for both groups was 36.1 weeks (adjusted p=0.73). 33.3% of live births in the laparoscopic cerclage group were preterm while 54.6% of live births in the abdominal cerclage group were preterm (adjusted p-value 0.79). No delivery complications occurred in either group. Of the 18 deliveries from the laparoscopic group, 5 newborns were admitted to the NICU and diagnosed with respiratory distress syndrome (RDS). Of the 11 deliveries from the laparotomy group, no newborns were admitted to NICU or diagnosed with RDS (Fisher’s exact test p-value=0.13). Conclusion: Laparoscopic transabdominal cerclage placement presents similar pregnancy outcomes as compared to traditional laparotomy approach. There is a non-significant increase risk of RDS/NICU admission in the laparoscopic group. However, based on our small sample size of neonatal outcomes, there may be insufficient power to detect a difference between the groups.
493 A Rare Case of an Autoamputated Ovary with Mature Cystic Teratoma Enveloped in Retroperitoneum Na YJ, Song YJ, Kim HG, Hong JE, Yoon HS, Lee SK. Department of Obstetrics & Gynecology, Pusan National University Yangsan Hospital, Yangsan-si, Gyeongsangnam-do, Republic of Korea Study Objective: Autoamputated ovary with mature cystic teratoma is a rarely reported gynecologic entity with an unknown prevalence. Design: Case report. Patients: A 41-year-old woman referred to our clinic for presumed left ovarian tumor. Pelvic examination, ultrasonography and CT scan revealed a 7-cm, cystic ovarian mass with calcification and fat component, and her serum CA125 was elevated to 68.3 U/mL. Laparoscopy was performed. The mass was identified in the cul-de-sac completely enveloped in the retroperitoneum without any ligamentous or direct connection with the pelvic organs. The right ovary was normal. However, the left ovary and tube could not be identified in its proper anatomical location. There was coffee bean sized mass attached to left infundibulopelvic ligament. Both adnexa had been normal on cesarean section 7 years ago at local clinic. The mass was successfully removed with sharp dissection from retroperitoneum and mesosigmoid colon by cooperation of general surgeon. Conclusion: Histopathologic study revealed a mature cystic teratoma. We present a rare case of an autoamputated ovary with mature cystic teratoma enveloped in retroperitoneum.
494 Unexpected Diagnosis of Smooth Muscle Tumor of Uncertain Malignant Potential after Laparoscopic Uterine Morcellation Ng VS, Zurawin RK. Dept. of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas Study Objective: Uterine smooth muscle tumor of uncertain malignant potential (STUMP) is a rare and poorly characterized subcategory of uterine smooth muscle tumors. A recent study demonstrates a 1.2% chance of an unexpected diagnosis of leiomyoma variants or atypical and malignant smooth muscle tumors in 1,091 instances of uterine
Abstracts / Journal of Minimally Invasive Gynecology 20 (2013) S133–S181 morcellation. We will discuss one patient who underwent a robotic-assisted laparoscopic myomectomy who was found to have STUMP. Patients: 33yo G1P0 with a history of infertility, pelvic pain and menorrhagia. Pelvic MRI demonstrated a 6.7 cm intramural fibroid with homogeneous enhancement consistent with a benign fibroid. Intervention: The patient underwent an uncomplicated robotic-assisted laparoscopic myomectomy. The specimen was morcellated and removed from the patient’s abdomen. Measurements and Main Results: Pathologic examination revealed focal mild atypia and no tumor cell necrosis. The mitotic rate was up to 19 per 10 high power fields. By Bell’s criteria these were consistent with STUMP. Conclusion: A smooth muscle tumor of uncertain malignant potential is very rare. Current scientific evidence demonstrates that pre-operative MRI cannot clearly distinguish between benign and malignant smooth muscle tumors. Thus, there is always the risk that laparoscopic myomectomy and subsequent morcellation of an unexpected STUMP can lead to dissemination of potentially malignant tissue in the peritoneal cavity. Because STUMP is such a rare entity it is difficult to determine the longterm consequences of morcellation. Fortunately, the few studies that have examined outcomes in patients with STUMP tumors demonstrate a low risk of recurrence and little effect on mortality. Therefore, careful observation and fertility-sparing management is an option in the typical myomectomy patient who desires to retain her uterus. This patient was counseled to maintain close follow up with a gynecologic oncologist including yearly physical and radiologic exams to monitor for possible recurrence. 495 Left Upper Quadrant Entry in Gynecologic Laparoscopy: A Single Center Experience Patel NR, Pereira N, Harris JP, Della. Badia CR. Obstetrics and Gynecology, Drexel University College of Medicine, Philadelphia, Pennsylvania Study Objective: To report our experience in utilizing left upper quadrant entry in gynecologic laparoscopic surgery. Design: Retrospective chart review. Setting: University-affiliated hospital. Patients: We included all patients who underwent robot-assisted or traditional laparoscopic surgery for benign gynecologic indications from January 2012 to January 2013. Measurements and Main Results: A total of 153 patients underwent gynecologic laparoscopic surgery during the study period. The same primary attending surgeon performed all surgeries. Rotating gynecology residents served as assistants during each surgery. Left upper quadrant entry under direct visualization was utilized in 110 (71.9%) patients. Patients who underwent surgery had a mean age of 44 (7.9) years, mean parity of 1.4 (1.2) and mean weight of 88.6 (25.4) kg. The most common previous surgery was cesarean delivery, which 43 (39.1%) patients underwent. While 21 (19.1%) patients had a previous history of laparotomy, 41 (37.2%) patients and 19 (17.2%) had previous laparoscopic and other abdominal surgery, respectively. The most common indication for left upper quadrant entry was a history of any previous abdominal surgery (83, 75.4% patients), followed by presence of large leiomyomata (10, 9.1% patients) and educational purposes (17, 15.5% patients). Intraabdominal adhesions were noted in 38 (34.5%) patients, most frequently in the vesicouterine (11, 24.4% patients) and umbilical regions (6, 13.3% patients). Abdominal entry using the left upper quadrant was successful in all patients. No entry-related complications were noted. Conclusion: Left upper quadrant entry during gynecologic laparoscopic surgery is a safe option in patients with intraabdominal adhesions or large abdominopelvic masses. In addition to its safety profile, our study indicates no failures associated with abdominal entry through the left upper quadrant. Despite these potential benefits, left upper quadrant entry is underutilized in gynecologic laparoscopic surgery.
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496 Uterine Manipulation during Laparoscopic Sterilization – Can We Do Without It? Prasad P, Livinti I, Simons M, Cuevas J, Lans C, Mikhail M. Obstetrics and Gynecology, Bronx Lebanon Hospital, Bronx, New York Study Objective: To assess the safety of laparoscopic tubal sterilization with and without any uterine manipulation and to compare the operating time in both groups. Design: Retrospective analysis of 164 patients who underwent laparoscopic sterilization. Setting: Bronx Lebanon Hospital Center- a community teaching hospital, Bronx, New York, USA. Patients: One hundred sixty four women between the ages of 23 and 48 years who underwent laparoscopic sterilization from January, 2005 to January, 2013. Intervention: Laparoscopic sterilization with and without uterine manipulation. Measurements and Main Results: Of 164 patients who completed surgery, 82 cases (50%) were performed with and 82 cases (50%) without uterine manipulation. The average time of surgery was 38.6 minutes in the group without manipulation and 42.5 minutes in the other group. Manipulators used in this study were- HUMI (Harrris-Kronner uterine manipulator injector), uterine manipulator, hulka manipulator, tenaculum with cervical dilator and ring forceps with sponge. Complications encountered in the group without uterine manipulation were - hematoma noted at the 5 mm entry port controlled with electrical cauterization, small bowel injury noted after entry- treated laparoscopically. Complications noted in the group with uterine manipulation were bleeding from the tenaculum site controlled with cauterization, ovarian dermoid cyst rupture leading to cystectomy, one case of uterine perforation by the HUMI managed by laparoscopic cauterization of perforation site. All patients were observed appropriately and discharged the same day of surgery except for one case (with uterine manipulation) that required overnight admission for observation after intraoperative extensive adhesiolysis. Both study groups had equal number of patients with history of previous abdominal surgeries leading to minimal to dense adhesions (sixteen in each). Conclusion: Performance of laparoscopic tubal ligation without any uterine manipulation from vagina is a safe and alternative option for patients desiring laparoscopic sterilization. History of previous abdominal surgeries is not a contraindication to performing laparoscopic sterilization without manipulation. 497 Parasitic Myoma: A Case Report Puga M, Redondo C, Alves J, Wattiez A. Department of Gynecologic Surgery, Strasbourg University Hospitals, IRCAD/EITS, Strasbourg, Bas Rhin, France Study Objective: We describe the case of several parasitic myomas in a patient with previous history of a laparoscopic myomectomy. Design: Case report. Setting: Strasbourg University Hospitals. Patients: 47 years old woman. Intervention: Surgical management of a pelvic mass. Among the patient’s antecedents there was a laparoscopic myomectomy performed six years before. Among the IRM findings, there was a heterogeneous and well limited pelvic mass, which measured 14 x 6,5 x 7 cm and evoked the image of a pedicled uterine fibroid. The patient desired uterine preservation, and was addressed for diagnostic and therapeutic laparoscopy. Measurements and Main Results: During the laparoscopy two parasitic myomas were found in the left and anterior pelvic walls. Both masses
Abstracts / Journal of Minimally Invasive Gynecology 20 (2013) S133–S181
Design: Retrospective chart review. Setting: University teaching hospital. Patients: Ninety-nine post-hysterectomy patients with adnexal mass. Intervention: Laparoscopic adenxal surgery. Measurements and Main Results: We reviewed patients’ clinical chart and operation records. The median age of the patients and BMI were 51 (34-80) years and 24.3 (18.1-36.0) kg/m2. The median values of operating time, change of the hemoglobin concentration, return of bowel activity, and hospital stay were 111 (35-470) min, 1.9 (0-5.1) g/dL, 32 (14-96) hours and 5 (2-36) days, respectively. The final histopathological results showed simple cyst (31.2%), mucinous cystadenoma (24.7%) and serous cystadenoma (16.1%) from the ovary and paratubal cyst (17.2%) and hydrosalpinx (16.1%) from the tube. Five out of 93 cases from ovary were confirmed ovarian malignancy. There were 10 cases of intraoperative and 7 cases of postoperative complications. There were no conversions to laparotomy. Conclusion: Concomitant bilateral salpingectomy in hysterectomy is feasible and efficient and it can be offered to eradicate the chance of unnecessary additional surgery resulting from tubal causes.
491 Combined Use of Vasopressin and Uterine Artery Ligation for Myomectomy in Large Uteri at Limited Resource Setting Magdum AA, Padiyath HR, Puthiyidom A, Trehan N. Obstetrics and Gynecology, Sunrise Hospital, Ernakulam, Kerala, India Study Objective: Prolonged procedure and excessive blood loss are main concerns during laparoscopic myomectomy especially for large uterine fibroids. Various methods are tried for hemostasis. We share our experience of combined intra-operative use of vasopressin and uterine artery ligation (performed after myomectomy and before closure of myoma bed) for hemostasis during laparoscopic myomectomy for large fibroids in limited resource center with an aim to evaluate safety and efficacy. Design: This is a retrospective analysis of women who have undergone laparoscopic myomectomy at a center with limited resources. Setting: Secondary level care center with limited resources. Patients: All women with large uterine size (24-30 weeks) who have undergone laparoscopic myomectomy during June 2011 till December 2011 were included in this study. Intervention: In study group women underwent vasopressin injection followed by myomectomy then uterine artery ligation at its origin before closure of myoma bed. In control group women underwent laparoscopic myomectomy with vasopressin alone or uterine artery ligation. In control group, uterine artery ligation was done before myomectomy. Measurements and Main Results: We analyzed and compared the parameters like size of uterus, parity, difficulty in performing uterine artery ligation, need for intra-operative and postoperative blood transfusion, length of hospital stay and intra-operative complications in study and the control group. We had 32 women in study group and 54 women in control group. The need for blood transfusion (intra and postoperative period) was significantly less in study group (nil) compared with control group (12.9%). The length of hospital stay (3 or more days) was lesser in study group compared with control group (nil v/s 12.9%). Uterine artery ligation was difficult in few of the cases from control group but in none from study group. Conclusion: During laparoscopic myomectomy for large uteri, combined use of vasopressin and uterine artery ligation before myomectomy bed closure is very useful method for hemostasis especially in limited resource settings. 492 Analysis of Neonatal Outcomes in Women after Cerclage Placement Manoucheri E, Cohen SL, Hill-Lydecker C, Einarsson JI. Brigham & Women’s Hospital, Boston, Massachusetts
Study Objective: To analyze the livebirth rate and neonatal outcomes following laparoscopic or abdominal cerclage placement. Design: Retrospective follow-up study of 37 women who had laparoscopic cerclage and 16 who had abdominal cerclages placed. Setting: University teaching hospital. Patients: 37 women who had laparoscopic cerclage and 16 who had abdominal cerclage placed. Measurements and Main Results: Of 37 patients who underwent laparoscopic cerclage placement, 26 became pregnant while 13 of the 16 women who had abdominal cerclages became pregnant (age, BMI, and gravidity adjusted p-value=0.97). Of those that became pregnant, 69% (18/ 26) who had laparoscopic cerclages had a livebirth compared with 85% (11/13) who had abdominal cerclages, adjusted p=0.68. Mean gestational age at time of delivery for both groups was 36.1 weeks (adjusted p=0.73). 33.3% of live births in the laparoscopic cerclage group were preterm while 54.6% of live births in the abdominal cerclage group were preterm (adjusted p-value 0.79). No delivery complications occurred in either group. Of the 18 deliveries from the laparoscopic group, 5 newborns were admitted to the NICU and diagnosed with respiratory distress syndrome (RDS). Of the 11 deliveries from the laparotomy group, no newborns were admitted to NICU or diagnosed with RDS (Fisher’s exact test p-value=0.13). Conclusion: Laparoscopic transabdominal cerclage placement presents similar pregnancy outcomes as compared to traditional laparotomy approach. There is a non-significant increase risk of RDS/NICU admission in the laparoscopic group. However, based on our small sample size of neonatal outcomes, there may be insufficient power to detect a difference between the groups.
493 A Rare Case of an Autoamputated Ovary with Mature Cystic Teratoma Enveloped in Retroperitoneum Na YJ, Song YJ, Kim HG, Hong JE, Yoon HS, Lee SK. Department of Obstetrics & Gynecology, Pusan National University Yangsan Hospital, Yangsan-si, Gyeongsangnam-do, Republic of Korea Study Objective: Autoamputated ovary with mature cystic teratoma is a rarely reported gynecologic entity with an unknown prevalence. Design: Case report. Patients: A 41-year-old woman referred to our clinic for presumed left ovarian tumor. Pelvic examination, ultrasonography and CT scan revealed a 7-cm, cystic ovarian mass with calcification and fat component, and her serum CA125 was elevated to 68.3 U/mL. Laparoscopy was performed. The mass was identified in the cul-de-sac completely enveloped in the retroperitoneum without any ligamentous or direct connection with the pelvic organs. The right ovary was normal. However, the left ovary and tube could not be identified in its proper anatomical location. There was coffee bean sized mass attached to left infundibulopelvic ligament. Both adnexa had been normal on cesarean section 7 years ago at local clinic. The mass was successfully removed with sharp dissection from retroperitoneum and mesosigmoid colon by cooperation of general surgeon. Conclusion: Histopathologic study revealed a mature cystic teratoma. We present a rare case of an autoamputated ovary with mature cystic teratoma enveloped in retroperitoneum.
494 Unexpected Diagnosis of Smooth Muscle Tumor of Uncertain Malignant Potential after Laparoscopic Uterine Morcellation Ng VS, Zurawin RK. Dept. of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas Study Objective: Uterine smooth muscle tumor of uncertain malignant potential (STUMP) is a rare and poorly characterized subcategory of uterine smooth muscle tumors. A recent study demonstrates a 1.2% chance of an unexpected diagnosis of leiomyoma variants or atypical and malignant smooth muscle tumors in 1,091 instances of uterine
Abstracts / Journal of Minimally Invasive Gynecology 20 (2013) S133–S181 morcellation. We will discuss one patient who underwent a robotic-assisted laparoscopic myomectomy who was found to have STUMP. Patients: 33yo G1P0 with a history of infertility, pelvic pain and menorrhagia. Pelvic MRI demonstrated a 6.7 cm intramural fibroid with homogeneous enhancement consistent with a benign fibroid. Intervention: The patient underwent an uncomplicated robotic-assisted laparoscopic myomectomy. The specimen was morcellated and removed from the patient’s abdomen. Measurements and Main Results: Pathologic examination revealed focal mild atypia and no tumor cell necrosis. The mitotic rate was up to 19 per 10 high power fields. By Bell’s criteria these were consistent with STUMP. Conclusion: A smooth muscle tumor of uncertain malignant potential is very rare. Current scientific evidence demonstrates that pre-operative MRI cannot clearly distinguish between benign and malignant smooth muscle tumors. Thus, there is always the risk that laparoscopic myomectomy and subsequent morcellation of an unexpected STUMP can lead to dissemination of potentially malignant tissue in the peritoneal cavity. Because STUMP is such a rare entity it is difficult to determine the longterm consequences of morcellation. Fortunately, the few studies that have examined outcomes in patients with STUMP tumors demonstrate a low risk of recurrence and little effect on mortality. Therefore, careful observation and fertility-sparing management is an option in the typical myomectomy patient who desires to retain her uterus. This patient was counseled to maintain close follow up with a gynecologic oncologist including yearly physical and radiologic exams to monitor for possible recurrence. 495 Left Upper Quadrant Entry in Gynecologic Laparoscopy: A Single Center Experience Patel NR, Pereira N, Harris JP, Della. Badia CR. Obstetrics and Gynecology, Drexel University College of Medicine, Philadelphia, Pennsylvania Study Objective: To report our experience in utilizing left upper quadrant entry in gynecologic laparoscopic surgery. Design: Retrospective chart review. Setting: University-affiliated hospital. Patients: We included all patients who underwent robot-assisted or traditional laparoscopic surgery for benign gynecologic indications from January 2012 to January 2013. Measurements and Main Results: A total of 153 patients underwent gynecologic laparoscopic surgery during the study period. The same primary attending surgeon performed all surgeries. Rotating gynecology residents served as assistants during each surgery. Left upper quadrant entry under direct visualization was utilized in 110 (71.9%) patients. Patients who underwent surgery had a mean age of 44 (7.9) years, mean parity of 1.4 (1.2) and mean weight of 88.6 (25.4) kg. The most common previous surgery was cesarean delivery, which 43 (39.1%) patients underwent. While 21 (19.1%) patients had a previous history of laparotomy, 41 (37.2%) patients and 19 (17.2%) had previous laparoscopic and other abdominal surgery, respectively. The most common indication for left upper quadrant entry was a history of any previous abdominal surgery (83, 75.4% patients), followed by presence of large leiomyomata (10, 9.1% patients) and educational purposes (17, 15.5% patients). Intraabdominal adhesions were noted in 38 (34.5%) patients, most frequently in the vesicouterine (11, 24.4% patients) and umbilical regions (6, 13.3% patients). Abdominal entry using the left upper quadrant was successful in all patients. No entry-related complications were noted. Conclusion: Left upper quadrant entry during gynecologic laparoscopic surgery is a safe option in patients with intraabdominal adhesions or large abdominopelvic masses. In addition to its safety profile, our study indicates no failures associated with abdominal entry through the left upper quadrant. Despite these potential benefits, left upper quadrant entry is underutilized in gynecologic laparoscopic surgery.
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496 Uterine Manipulation during Laparoscopic Sterilization – Can We Do Without It? Prasad P, Livinti I, Simons M, Cuevas J, Lans C, Mikhail M. Obstetrics and Gynecology, Bronx Lebanon Hospital, Bronx, New York Study Objective: To assess the safety of laparoscopic tubal sterilization with and without any uterine manipulation and to compare the operating time in both groups. Design: Retrospective analysis of 164 patients who underwent laparoscopic sterilization. Setting: Bronx Lebanon Hospital Center- a community teaching hospital, Bronx, New York, USA. Patients: One hundred sixty four women between the ages of 23 and 48 years who underwent laparoscopic sterilization from January, 2005 to January, 2013. Intervention: Laparoscopic sterilization with and without uterine manipulation. Measurements and Main Results: Of 164 patients who completed surgery, 82 cases (50%) were performed with and 82 cases (50%) without uterine manipulation. The average time of surgery was 38.6 minutes in the group without manipulation and 42.5 minutes in the other group. Manipulators used in this study were- HUMI (Harrris-Kronner uterine manipulator injector), uterine manipulator, hulka manipulator, tenaculum with cervical dilator and ring forceps with sponge. Complications encountered in the group without uterine manipulation were - hematoma noted at the 5 mm entry port controlled with electrical cauterization, small bowel injury noted after entry- treated laparoscopically. Complications noted in the group with uterine manipulation were bleeding from the tenaculum site controlled with cauterization, ovarian dermoid cyst rupture leading to cystectomy, one case of uterine perforation by the HUMI managed by laparoscopic cauterization of perforation site. All patients were observed appropriately and discharged the same day of surgery except for one case (with uterine manipulation) that required overnight admission for observation after intraoperative extensive adhesiolysis. Both study groups had equal number of patients with history of previous abdominal surgeries leading to minimal to dense adhesions (sixteen in each). Conclusion: Performance of laparoscopic tubal ligation without any uterine manipulation from vagina is a safe and alternative option for patients desiring laparoscopic sterilization. History of previous abdominal surgeries is not a contraindication to performing laparoscopic sterilization without manipulation. 497 Parasitic Myoma: A Case Report Puga M, Redondo C, Alves J, Wattiez A. Department of Gynecologic Surgery, Strasbourg University Hospitals, IRCAD/EITS, Strasbourg, Bas Rhin, France Study Objective: We describe the case of several parasitic myomas in a patient with previous history of a laparoscopic myomectomy. Design: Case report. Setting: Strasbourg University Hospitals. Patients: 47 years old woman. Intervention: Surgical management of a pelvic mass. Among the patient’s antecedents there was a laparoscopic myomectomy performed six years before. Among the IRM findings, there was a heterogeneous and well limited pelvic mass, which measured 14 x 6,5 x 7 cm and evoked the image of a pedicled uterine fibroid. The patient desired uterine preservation, and was addressed for diagnostic and therapeutic laparoscopy. Measurements and Main Results: During the laparoscopy two parasitic myomas were found in the left and anterior pelvic walls. Both masses