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Using Uterine Manipulator VMG 3-AA in Total Laparoscopic Hysterectomy in Patients with Large Uterine Fibroids
Abstracts / Journal of Minimally Invasive Gynecology 20 (2013) S133–S181 year of surgery, beginning in 2007 when the robotic surgical system was introduced. During the following five years, the rate of hysterectomy performed via laparotomy decreased from 66.67-71.01% (2007) to 30.9934.80% (2012), p-value \0.001. In contrast, the rate of robotically assisted hysterectomy increased from 1.89% (2007) to 40.53-45.07% (2012), p-value \0.001. At no time period did the rates plateau. Laparoscopic hysterectomy rates increased from 0.56-2.36% (2007) to 6.61-9.69% (2012), p-value \0.001. Declines were seen in both vaginal hysterectomy (12.26-20.00% (2007) to 8.92-10.33% (2012), p-value \0.001) and laparoscopically assisted vaginal hysterectomy (11.5917.37% (2007) to 4.85-6.10% (2012), p-value\0.001) over the same period.
S155
Conclusion: Literature describes embolization as treatment for AV malformation. However, known side effects of embolization can include severe pain. Our patient had no desire for future childbearing and given her severe pain and hemoperitoneum, hysterectomy was felt to be in this patient’s best interest. This multi-disciplinary approach allowed minimally invasive hysterectomy to be safely completed, minimizing blood loss.
VIRTUAL POSTER: NEW INSTRUMENTATION 520 Using Uterine Manipulator VMG 3-AA in Total Laparoscopic Hysterectomy in Patients with Large Uterine Fibroids Adamyan L,1 Kiselev S,2 Stepanian A,3 Arakelyan A.1 1Russian Scientific Center of Obstetrics, Gynecology and Perinatology, Moscow, Russian Federation; 2Reproductive Medicine and Surgery, Moscow State University for Medicine and Dentistry, Moscow, Russian Federation; 3 Academia of Women’s Health and Endoscopic Surgery, Atlanta, Georgia
Conclusion: The percentage of robotically assisted hysterectomies dramatically increased over the five years of utilization and by 2012 had become the primary modality for performing hysterectomy at a single institution. With the exception of laparoscopic hysterectomy, this has resulted in a decline in all other approaches to hysterectomy when compared to trends prior to introduction of robotic assistance. 519 Uterine Arteriovenous Malformation Embolization Allowing Minimally Invasive Hysterectomy: An Interesting Case of Acute Pelvic Pain Yi J, Magtibay PM. Gynecologic Surgery, Mayo Clinic Arizona, Phoenix, Arizona Study Objective: We describe a multi-disciplinary approach to a patient with pelvic pain and uterine arteriovenous malformation that allowed minimally invasive hysterectomy and safely prevented laparotomy. Design: Case Report. Setting: Tertiary Care Academic Hospital. Patients: Our patient presented to the Emergency Room with acute onset pelvic pain. Evaluation with CT scan showed small hemoperitoneum, no visible ovarian cysts, but significant uterine arteriovenous malformation. Patient’s history was significant for a pregnancy termination via D&C. She also had complaints of menorrhagia which had not been evaluated previously. Patient also had a history of narcotic use from prior orthopedic pain and had difficulty with pain control despite intravenous narcotics. Given the size of the AV malformation along with presenting symptom of pain, decision was made to proceed with surgical evaluation with IR embolization first. Patient had no future desire for fertility. Intervention: Femoral artery was catheterized and GelFoam was used to embolize the right and left uterine arteries. She was immediately taken to the operating room and performed diagnostic laparoscopy, total laparoscopic hysterectomy, and cystoscopy. Intraoperative findings showed a hemorrhagic corpus luteum cyst with dilated uterine and ovarian vessels. Uterine arteries were ligated at their origin and extrafascial hysterectomy was performed. Estimated blood loss was 300mL including approximately 100mL hemoperitoneum. Measurements and Main Results: Postoperatively, patient was discharged with adequate oral pain control on postoperative day 2. Patient was off oral narcotics by her 6 week postoperative visit and suffered no postoperative complications.
Study Objective: We have designed the BMg-AK3 (Russian patent RU 2311883 C1) uterine manipulator that has advantages to currently existing models as to management of patients with the myoma of the large size. Design: 93 patients with large uterine fibroids underwent total laparoscopic hysterectomy with the BMg-AK3 uterine manipulator. Intraoperative outcomes were measured. Setting: Russian Federal Institute Scientific Center of Obstetrics, Gynecology and Perinatology Named after VI Kulakov. Patients: 93 patients with large uterine fibroids undergoing laparoscopic hysterectomy. Intervention: Laparoscopic hystrectomy using BMG-AK3 in patient with large uterine fibroids. Measurements and Main Results: We designed the BMg-AK3 (Russian patent RU 2311883 C1) uterine manipulator in an effort to enhance the degree and comfort of uterine manipulation during hystrectomy for large uterine myoma. This was achieved through: 1. Enhanced rigidity and reliability for sustaining significant axial loads; 2. Presence of a ‘‘christmas tree-type’’ 4 cm long locking mechanism; 3. Presence of various sizes of manipulator tipis ranging between 4 and 12 cm; 4. The manipulator is equipped with a 3 or 4-level latex cuff to prevent loss of pneumoperitoneum and to expose the vaginal vault. Hysterectomy duration ranged from 45 to 205 minutes (97,25 min). Uterine weight ranged from 300 to 2470 g (790,5 g). The average volume of intraoperative blood loss was 173,22 ml. There was no transition to laparotomy. Conclusion: When performing total laparoscopic hysterectomy in patients with large uterine fibroids, the BMg-AK3 non-disposable uterine manipulator allows for the following essential qualities: reliable rigidity to allow for sustainable increased axial loads, appropriate tissue fixation capabilities, variability in lengths of the tips, enhanced ergonomics of the tip and well as appropriate vaginal vault presenting capabilities and preservation of pneumoperitoneum. By enhancing such qualities this non-disposable manipulator is compatible with current manipulator and may potentially present itself as superior to them when handling myoma of the large size. 521 Flexible CO2 Laser Vs. Ultrasonic Scalpel in Robot-Assisted Laparoscopic Myomectomy Choussein S, Srouji SS, Missmer SA, Gargiulo AR. Center for Infertility and Reproductive Surgery, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts Study Objective: Photonic and ultrasonic energy provide highly effective cutting and coagulation with a lesser extent of collateral thermal damage compared to electrosurgery. We aim to compare the effectiveness and safety of a flexible CO2 laser fiber to the ultrasonic scalpel when employed through a robotic surgical system. Design: Retrospective cohort study.
S155
Conclusion: Literature describes embolization as treatment for AV malformation. However, known side effects of embolization can include severe pain. Our patient had no desire for future childbearing and given her severe pain and hemoperitoneum, hysterectomy was felt to be in this patient’s best interest. This multi-disciplinary approach allowed minimally invasive hysterectomy to be safely completed, minimizing blood loss.
VIRTUAL POSTER: NEW INSTRUMENTATION 520 Using Uterine Manipulator VMG 3-AA in Total Laparoscopic Hysterectomy in Patients with Large Uterine Fibroids Adamyan L,1 Kiselev S,2 Stepanian A,3 Arakelyan A.1 1Russian Scientific Center of Obstetrics, Gynecology and Perinatology, Moscow, Russian Federation; 2Reproductive Medicine and Surgery, Moscow State University for Medicine and Dentistry, Moscow, Russian Federation; 3 Academia of Women’s Health and Endoscopic Surgery, Atlanta, Georgia
Conclusion: The percentage of robotically assisted hysterectomies dramatically increased over the five years of utilization and by 2012 had become the primary modality for performing hysterectomy at a single institution. With the exception of laparoscopic hysterectomy, this has resulted in a decline in all other approaches to hysterectomy when compared to trends prior to introduction of robotic assistance. 519 Uterine Arteriovenous Malformation Embolization Allowing Minimally Invasive Hysterectomy: An Interesting Case of Acute Pelvic Pain Yi J, Magtibay PM. Gynecologic Surgery, Mayo Clinic Arizona, Phoenix, Arizona Study Objective: We describe a multi-disciplinary approach to a patient with pelvic pain and uterine arteriovenous malformation that allowed minimally invasive hysterectomy and safely prevented laparotomy. Design: Case Report. Setting: Tertiary Care Academic Hospital. Patients: Our patient presented to the Emergency Room with acute onset pelvic pain. Evaluation with CT scan showed small hemoperitoneum, no visible ovarian cysts, but significant uterine arteriovenous malformation. Patient’s history was significant for a pregnancy termination via D&C. She also had complaints of menorrhagia which had not been evaluated previously. Patient also had a history of narcotic use from prior orthopedic pain and had difficulty with pain control despite intravenous narcotics. Given the size of the AV malformation along with presenting symptom of pain, decision was made to proceed with surgical evaluation with IR embolization first. Patient had no future desire for fertility. Intervention: Femoral artery was catheterized and GelFoam was used to embolize the right and left uterine arteries. She was immediately taken to the operating room and performed diagnostic laparoscopy, total laparoscopic hysterectomy, and cystoscopy. Intraoperative findings showed a hemorrhagic corpus luteum cyst with dilated uterine and ovarian vessels. Uterine arteries were ligated at their origin and extrafascial hysterectomy was performed. Estimated blood loss was 300mL including approximately 100mL hemoperitoneum. Measurements and Main Results: Postoperatively, patient was discharged with adequate oral pain control on postoperative day 2. Patient was off oral narcotics by her 6 week postoperative visit and suffered no postoperative complications.
Study Objective: We have designed the BMg-AK3 (Russian patent RU 2311883 C1) uterine manipulator that has advantages to currently existing models as to management of patients with the myoma of the large size. Design: 93 patients with large uterine fibroids underwent total laparoscopic hysterectomy with the BMg-AK3 uterine manipulator. Intraoperative outcomes were measured. Setting: Russian Federal Institute Scientific Center of Obstetrics, Gynecology and Perinatology Named after VI Kulakov. Patients: 93 patients with large uterine fibroids undergoing laparoscopic hysterectomy. Intervention: Laparoscopic hystrectomy using BMG-AK3 in patient with large uterine fibroids. Measurements and Main Results: We designed the BMg-AK3 (Russian patent RU 2311883 C1) uterine manipulator in an effort to enhance the degree and comfort of uterine manipulation during hystrectomy for large uterine myoma. This was achieved through: 1. Enhanced rigidity and reliability for sustaining significant axial loads; 2. Presence of a ‘‘christmas tree-type’’ 4 cm long locking mechanism; 3. Presence of various sizes of manipulator tipis ranging between 4 and 12 cm; 4. The manipulator is equipped with a 3 or 4-level latex cuff to prevent loss of pneumoperitoneum and to expose the vaginal vault. Hysterectomy duration ranged from 45 to 205 minutes (97,25 min). Uterine weight ranged from 300 to 2470 g (790,5 g). The average volume of intraoperative blood loss was 173,22 ml. There was no transition to laparotomy. Conclusion: When performing total laparoscopic hysterectomy in patients with large uterine fibroids, the BMg-AK3 non-disposable uterine manipulator allows for the following essential qualities: reliable rigidity to allow for sustainable increased axial loads, appropriate tissue fixation capabilities, variability in lengths of the tips, enhanced ergonomics of the tip and well as appropriate vaginal vault presenting capabilities and preservation of pneumoperitoneum. By enhancing such qualities this non-disposable manipulator is compatible with current manipulator and may potentially present itself as superior to them when handling myoma of the large size. 521 Flexible CO2 Laser Vs. Ultrasonic Scalpel in Robot-Assisted Laparoscopic Myomectomy Choussein S, Srouji SS, Missmer SA, Gargiulo AR. Center for Infertility and Reproductive Surgery, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts Study Objective: Photonic and ultrasonic energy provide highly effective cutting and coagulation with a lesser extent of collateral thermal damage compared to electrosurgery. We aim to compare the effectiveness and safety of a flexible CO2 laser fiber to the ultrasonic scalpel when employed through a robotic surgical system. Design: Retrospective cohort study.