Comparison of Postoperative Complications Between Laparoscopic Myomectomy and Total Laparoscopic Hysterectomy.

STUDY OBJECTIVE: To compare postoperative complications of laparoscopic myomectomy (LM) with total laparoscopic hysterectomy (TLH). A secondary outcome examined whether complications differ by age. DESIGN: A retrospective cohort study. SETTING: A multicenter academic healthcare system. PATIENTS: Individuals > 18 years old undergoing LM from 2011 to 2021 or TLH for benign indications from 2020 to 2021. INTERVENTIONS: LM or TLH. MEASUREMENTS AND MAIN RESULTS: There were 1178 patients in the LM group and 1304 in the TLH group. Patients who underwent LM were younger, more often premenopausal, nonsmokers, with lower body mass index, lower preoperative hemoglobin, larger uterine size, and lower American Society of Anesthesiologists class. LM had longer operative times (154.1 ± 74.5 vs 145.9 ± 70.5 min, p <.0001), higher use of intraoperative hemostatic agents (25% vs 9.1%, p <.0001), and higher estimated blood loss (222.7 ± 313.0 vs 87.4 ± 145.9 mL, p <.0001) than TLH. Postoperatively, LM was associated with fewer surgical site infections (3.1% vs 5.8%, p <.0001), readmissions within 30 days (2.0% vs 5.6%, p <.0001), or emergency department visits within 90 days (10.9% vs 14.4%, p = .008). LM were more likely to be admitted 24 hours postoperatively (5.9% vs 3.4%, p = .0023) or receive a blood transfusion within 30 days (4.0% vs 1.0%, p <.0001). Variables associated with increased risk of postoperative complications were tobacco use, American Society of Anesthesiologists class > 3, preoperative anemia, estimated blood loss ≥ 150 mL, and specimen weight > 250 g. Logistic regression demonstrated that operative time ≥185 minutes was most strongly associated with 24-hour admission postoperatively (odds ratio [OR] = 12.95; 95% confidence interval [CI], 3.71-45.27). In individuals ≤ 37 years of age, the LM group was less likely than the TLH group to experience surgical site infection (OR, 0.30; 95% CI, 0.14-0.62) or present to the emergency department (OR, 0.40; 95% CI, 0.26-0.63). CONCLUSION: In this large cohort of patients, both LM and TLH had low rates of postoperative complications, but the complications differed for each approach. In appropriate surgical candidates, either approach may be offered based upon patients' goals.

Anatomy of the Internal Iliac Vein: Implications for Uterine Transplant.

STUDY OBJECTIVE: Uterine transplantation has proven feasible since the first live birth reported in 2014. To enable attachment of the uterus in the recipient, long vascular pedicles of the uterine and internal iliac vessels were obtained during donor hysterectomy, which required a prolonged laparotomy to the living donors. To assist further attempts at uterine transplantation, our video serves to review literature reports of internal iliac vein anatomy and demonstrate a laparoscopic dissection of cadaver pelvic vascular anatomy. DESIGN: Observational (Canadian Task Force Classification III). SETTING: Academic anatomic laboratory. Institutional Review Board ruled that approval was not required for this study. INTERVENTION: Literature review and laparoscopic dissection of cadaveric pelvic vasculature, focusing on the internal iliac vein. MEASUREMENTS AND MAIN RESULTS: Although the internal iliac artery tends to have minimal anatomic variation, its counterpart, the internal iliac vein, shows much variation in published studies [1,2]. Relative to the internal iliac artery, the vein can lie medially or laterally. Normal anatomy is defined as some by meeting 2 criteria: bilateral common iliac vein formed by ipsilateral external and internal iliac vein at a low position and bilateral common iliac vein joining to form a right-sided inferior vena cava [2]. Reports show 79.1% of people have normal internal iliac vein anatomy by these criteria [2]. The cadaver dissection revealed internal iliac vein anatomy meeting criteria for normal anatomy. CONCLUSION: Understanding the complexity and variations of internal iliac vein anatomy can assist future trials of uterine transplantation.

Sterility of Selected Operative Sites During Total Laparoscopic Hysterectomy.

STUDY OBJECTIVE: To describe the type and quantity of bacteria found intraoperatively on the abdomen, vagina, surgical gloves, instrument tips, and uterus at distinct time points during total laparoscopic hysterectomy (TLH). DESIGN: Observational study (Canadian Task Force classification III). SETTING: Academic affiliated hospital. PATIENTS: Thirty-one women undergoing TLH for benign indications in 2016. INTERVENTIONS: After antibiotic prophylaxis and chlorhexidine preparation, swabs were collected from the vaginal fornices and abdomen. During subsequent TLH, additional swabs were collected from the following sites: surgeon's gloves after placement of the uterine manipulator, tips of instruments used to close the vaginal cuff, uterine fundus after extraction, and surgeon's gloves after removal of the uterus. A calibrated loop was used to inoculate each specimen onto 5% blood and chocolate agars for growth of aerobes and onto Brucella blood, phenylethyl alcohol, kanamycin vancomycin, and Bacteroides bile esculin agars for growth of anaerobes. Manual colony counts were tabulated for all positive cultures and reported in colony-forming units per milliliter (CFU/mL). MEASUREMENTS AND MAIN RESULTS: Anaerobic growth was not seen on the instrument tips, in the vagina, or on the abdomen of any patient. Aerobic bacterial growth was not seen in the vagina of any patient. On the surgeon's gloves after uterine manipulator placement, no patients demonstrated sufficient bacterial growth to potentially cause surgical site infection (≥5000 CFU/mL). On the surgeon's gloves following uterine extraction, 1 patient demonstrated sufficient growth to potentially cause infection. None of the patients developed surgical site infections postoperatively. CONCLUSION: Cultures from multiple operative sites yielded bacterial growth, but the bacterial concentrations did not exceed the threshold for infection in 98.9% of cultures. Given absent growth from vaginal cultures and rare growth from abdominal cultures, chlorhexidine gluconate 4% is considered an appropriate surgical preparation for use in laparoscopic hysterectomy.

Uterine viability in the baboon after ligation of uterine vasculature: a pilot study to assess alternative perfusion and venous return for uterine transplantation.

OBJECTIVE: To assess, in two separate groups of baboons, uterine viability after ligation of the uterine veins and uterine viability after ligation of both the uterine arteries and veins, respectively. DESIGN: Prospective, observational study. SETTING: Baboon breeding colony. ANIMAL(S): Six naïve female Papio hamadryas baboons with indicators of normal reproductive function. INTERVENTION(S): Three baboons underwent surgical interruption of the uterine veins bilaterally, and three baboons underwent surgical interruption of the uterine arteries and the uterine veins bilaterally. All baboons also underwent colpotomy, cervico-vaginal reanastomosis, and intraoperative near-infrared fluorescence imaging after vessel ligation. In the postoperative period, transabdominal sonography, vaginoscopy, and endocervical biopsy were performed on all animals. MAIN OUTCOME MEASURE(S): Postoperative uterine and ovarian viability. RESULT(S): Near-infrared imaging confirmed intraoperative perfusion of the uterus and cervico-vaginal anastomosis in all cases. In all subjects, sonography revealed normal uteri, and vaginoscopy revealed well-healed anastomoses. Endocervical biopsies (five of six) demonstrated pathologically normal endocervical tissue without evidence of necrosis. Cyclical sex skin turgescence and menstruation were unanimously observed. CONCLUSION(S): Disruption of bilateral uterine vessels does not affect uterine or ovarian viability in the baboon. Bilateral uterine artery and vein ligation furthers development of a minimally invasive approach to donor hysterectomy.

Laser Angiography with Indocyanine Green to Assess Vaginal Cuff Perfusion during Total Laparoscopic Hysterectomy: A Pilot Study.

STUDY OBJECTIVE: To determine feasibility of using laser angiography with indocyanine green (ICG) to assess vaginal cuff vascular perfusion during total laparoscopic hysterectomy (TLH). DESIGN: Pilot feasibility trial (Canadian Task Force classification II-2). SETTING: Academic-affiliated hospital. PATIENTS: Twenty women undergoing TLH for benign disease. INTERVENTIONS: Participants underwent 1:1 randomization of energy method used for colpotomy (ultrasonic vs monopolar) and vaginal cuff closure suture (barbed vs nonbarbed). After intravenous administration of ICG, laser angiography was used to capture images of the vaginal cuff before and after closure. Three reviewers analyzed fluorescent images of vaginal cuffs to determine percent of cuff perimeter with adequate perfusion when open and length of vaginal cuff adequately perfused when closed. MEASUREMENTS AND MAIN RESULTS: ICG fluorescence was visible at the vaginal cuff in all participants. Mean time to appearance of ICG in the pelvis after administration was 19.8 ± 6.8 seconds (mean ± SD) preclosure, and 26.0 ± 22.2 seconds postclosure. With ultrasonic energy 67.5% ± 17.4% of open cuff perimeter and 74.4% ± 20.5% of closed cuff length were adequately perfused, whereas with monopolar energy use 59.1% ± 17.4% of the open cuff perimeter and 66.3% ± 15.4% of closed cuff length were adequately perfused. Cuffs closed with barbed suture showed adequate perfusion along 71.5% ± 15.1% of the length, whereas those closed with nonbarbed suture showed 68.9% ± 20.9% adequate perfusion. When normalized to cervical cup circumference, ultrasonic energy required 1.0 ± .2 s/mm, whereas monopolar energy required .8 ± .3 s/mm (p = .162). Linear regression showed no association of normalized time of energy activation to percentage of perimeter of open cuff (R2 = .007) or length of closed cuff (R2 = .005) with adequate perfusion. No complications related to intravenous ICG administration occurred. CONCLUSION: Laser angiography with ICG allows evaluation of vascular perfusion at the vaginal cuff during TLH. This technique may facilitate future prospective studies examining causes for vaginal cuff dehiscence, a complication with potential for severe morbidity.

Assessment of an Alternative to the Uterine Vein for Venous Drainage in Human Uterine Transplantation: A Case Series Following Laparoscopic Hysterectomy.

BACKGROUND/AIMS: To determine an alternative to the uterine vein, considering the utero-ovarian vein (UOV) for venous drainage in human uterine transplantation. METHODS: A case series of 10 total laparoscopic hysterectomies was conducted for benign indications and a vascular study was performed ex vivo on the surgical specimen, demonstrating ipsilateral and contralateral flow between the uterine artery (UA) and UOV visualizing anastomoses between these vessels. The flow pattern was documented using heparinized saline and illustrated through fluoroscopy using Isovue-300 dye. RESULTS: Successful cannulation of UA was accomplished in all 10 cases. Ipsilateral flow between the UA and UOV was demonstrated in all except one case, and contralateral flow was observed. Due to the long interval between the time of specimen retrieval and vascular study, the time to cannulation limited the ability to demonstrate ipsilateral and contralateral flow in 2 cases. CONCLUSION: Uterine transplantation has become a viable option for women with absolute uterine factor infertility. However, this surgery requires extensive surgical dissection, and the surgical retrieval of the uterine vein proposes a challenge. We present a potential option for venous drainage in uterine transplant surgery, considering the UOV for venous drainage as an alternative to the uterine vein and a possibility for minimally invasive approach.

Giant cystic degeneration of a uterine leiomyoma in a patient with autosomal dominant polycystic kidney disease.

OBJECTIVE: To report the management of a large uterine leiomyoma with diffuse cystic degeneration in a patient with autosomal dominant polycystic kidney disease (ADPKD). DESIGN: Case Report. SETTING: Cleveland Clinic Florida, Department of Gynecology, Section of Minimally Invasive Gynecologic surgery, Weston Florida. PATIENTS: A 52-year old woman with ADPKD with a large abdominal mass, abnormal uterine bleeding and symptomatic anemia. Imaging revealed a giant intramural cystic lesion of the uterus compressing the inferior vena cava. INTERVENTIONS: Uterine artery embolization and blood transfusion followed by a computed tomography guided cyst aspiration were performed on admission to alleviate anemia and abdominal pain and distension. Total laparoscopic hysterectomy with bilateral salpingectomy was performed in an outpatient setting. MAIN OUTCOME MEASURES: Management of large cystic degeneration of leiomyoma. RESULTS: Normal recovery from definitive surgery. Surgical pathology confirmed a benign, cystically dilated leiomyoma. CONCLUSION: This case demonstrates the management of giant intramural cyst lesion of the uterus using a minimally invasive surgical approach, as opposed to emergency surgery via laparotomy. CAPSULE: Large uterine leiomyoma with diffuse cystic degeneration in a patient with autosomal dominant polycystic kidney disease, in which step-wise treatments allows successful minimally invasive hysterectomy.