A Simple Approach to Specimen Retrieval via Posterior Colpotomy Incision.

INTRODUCTION: Posterior colpotomy incision for specimen retrieval is infrequently used in gynecologic laparoscopic surgery unless a concomitant hysterectomy is performed. We aim to describe a simple and unique technique for creating the colpotomy incision and to describe intraoperative and postoperative outcomes. METHODS: Fifty patients underwent adnexal specimen retrieval through a posterior colpotomy incision. After devascularization and detachment of the adnexal specimen, the posterior cul-de-sac was visualized. The colpotomy incision was created by introducing a 12- or 15-mm laparoscopic trocar through the vagina into the posterior vaginal fornix under direct visualization. Specimens were placed into laparoscopic bags and removed through the vagina. The colpotomy incision was closed vaginally. Charts were reviewed for intraoperative and postoperative outcomes. RESULTS: Twenty-nine women underwent adnexal surgery for an adnexal mass, 14 women underwent surgery for pelvic pain, and 7 women underwent adnexal surgery for primary prevention of malignancy. The specimens removed ranged in size from 2 to 16 cm (mean 5.7). The mean time patients were under anesthesia was 103 minutes (SD 57.3). There were no operative complications related to the colpotomy incision and no cases of postoperative vaginal cellulitis or pelvic infection were reported. Only 1 woman with a prior vaginal delivery reported dyspareunia postoperatively. CONCLUSION: This simple technique for posterior colpotomy incision can easily be added to the gynecologic surgeon's armamentarium and can be safely used for most women.

Incidental ureteral injury and repair during robotic-assisted total laparoscopic hysterectomy.

STUDY OBJECTIVE: To show a surgical educational video in which an incidental ureteral injury was recognized intraoperatively and was repaired during robotic-assisted total hysterectomy for a very large uterus. DESIGN: Step-by-step demonstration of ureterolysis and repair of ureteral injury via a ureteroureterostomy technique using an educational video and schematic pictures. SETTING: Ureteral injuries are estimated to occur with a frequency of approximately 0.02% to 0.4% during laparoscopic hysterectomy. When compared with bladder injuries, ureteral injuries are much less likely to be recognized intraoperatively, and in some cases can be missed despite the use of intraoperative cystoscopy. The sequelae from ureteral injury are not insignificant, which can easily be prevented by intraoperative recognition and immediate repair. Minimally invasive surgery using the robotic system has led to a paradigm shift in the management of urinary tract injuries, which has been traditionally approached with open surgery. INTERVENTIONS: Robotic total hysterectomy and repair of incidental ureteral injury via ureteroureterostomy using standard end-to-end anastomosis technique and intracorporeal retrograde double J stent placement. CONCLUSION: Robotic repair of ureteral injury during gynecologic surgery was associated with good outcomes, appeared safe and feasible, and saved the patient and the physician significant morbidity and medicolegal implications, respectively.

Needleless laparoscopic abdominal cerclage placement.

STUDY OBJECTIVE: To show a technique of laparoscopic interval abdominal cerclage placement with the use of a needleless mersilene tape. DESIGN: Step-by-step explanation of the technique using a surgical video. SETTING: Cervical insufficiency affects 1% of all pregnancies and up to 8% of those with second and early third trimester losses. The abdominal method has been used in patients with an extremely short cervix in whom the transvaginal approach is not technically possible or for those who have experienced an unsuccessful transvaginal procedure. With the introduction of the transabdominal cerclage, the fetal survival rate improved from 21% to 89%. In an attempt to decrease the surgical morbidity associated with laparotomy, there have been multiple case series and cohort studies in the literature that described the laparoscopic approach for transabdominal cerclage placement. INTERVENTIONS: Laparoscopic abdominal cerclage placement was performed as an interval procedure using needleless mersilene tape after meticulous skeletonization of the uterine vessels and formation of the peritoneal window. CONCLUSION: Laparoscopic abdominal cerclage was placed without any complications, providing the patient with the benefits of minimally invasive approach. The risk of bleeding was reduced by meticulous dissection and skeletonization of uterine vessels and eliminating the use of the mersilene tape needle.

Reproductive coercion and co-occurring intimate partner violence in obstetrics and gynecology patients.

OBJECTIVE: Reproductive coercion is male behavior to control contraception and pregnancy outcomes of female partners. We examined the prevalence of reproductive coercion and co-occurring intimate partner violence among women presenting for routine care at a large, urban obstetrics and gynecology clinic. STUDY DESIGN: Women aged 18-44 years completed a self-administered, anonymous survey. Reproductive coercion was defined as a positive response to at least 1 of 14 questions derived from previously published studies. Women who experienced reproductive coercion were also assessed for intimate partner violence in the relationship where reproductive coercion occurred. RESULTS: Of 641 women who completed the survey, 16% reported reproductive coercion currently or in the past. Among women who experienced reproductive coercion, 32% reported that intimate partner violence occurred in the same relationship. Single women were more likely to experience reproductive coercion as well as co-occurring intimate partner violence. CONCLUSION: Reproductive coercion with co-occurring intimate partner violence is prevalent among women seeking general obstetrics and gynecology care. Health care providers should routinely assess reproductive-age women for reproductive coercion and intimate partner violence and tailor their family planning discussions and recommendations accordingly.

Role of routine monitoring of liver and renal function during treatment of ectopic pregnancies with single-dose methotrexate protocol.

OBJECTIVE: To assess whether or not baseline serum transaminases and creatinine measurements, before administration of methotrexate, identified significant liver or kidney disease, which have the potential to alter the management plan for the treatment of ectopic pregnancies. DESIGN: This is a retrospective study of patients treated for ectopic pregnancy. SETTING: Women's emergency room and reproductive endocrinology office at a teaching hospital over a 3-year period. PATIENT(S): Women presenting for treatment of ectopic pregnancy. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Assessment of baseline serum transaminases and creatinine measurements before administration of methotrexate to identify significant liver or kidney disease. RESULT(S): A total of 383 patients were managed for ectopic pregnancy from January 2006 to December 2008. Of these, 320 patients received methotrexate as part of their treatment. No patient was denied treatment with methotrexate secondary to concerns regarding liver or renal function. No complication related to methotrexate administration was documented. A subgroup of 81 patients had pre- and postadministration labs, and no significant difference was noted upon comparing the values. CONCLUSION(S): Routine measurement of serum aspartate aminotransferase and creatinine levels may not be necessary before instituting a single-dose methotrexate treatment regimen for the management of ectopic pregnancy.