How to minimize bleeding in laparoscopic myomectomy.

PURPOSE OF REVIEW: Laparoscopic myomectomy is a common surgical procedure for symptomatic myomas. However, bleeding control during surgery may pose a challenge. Therefore, the aim of this study was to review recent evidence regarding interventions to control bleeding during laparoscopic myomectomy. RECENT FINDINGS: The use of vasopressin resulted in less blood loss compared to placebo. Barbed sutures reduced blood loss compared to conventional sutures. Intravenous infusion of tranexamic acid (TXA) in the intraoperative period of large myomectomies showed no significant difference compared to placebo. Uterine artery occlusion (UAO) and emergency uterine artery embolization were reported to be feasible and may reduce and treat bleeding before conversion to laparotomy. SUMMARY: Several methods can control bleeding during laparoscopic myomectomy. Vasopressin and barbed sutures resulted in decreased blood loss, and TXA did not have an impact on bleeding control. The use of UAO and emergency embolization techniques can contribute to the control of bleeding; however, further studies are needed to prove the efficacy of these and other agents.

Useful Pelvic Retroperitoneal Neuroanatomy for Benign Gynecologic Surgery: A Cadaveric Dissection.

OBJECTIVE: Knowledge of the retroperitoneal anatomy is particularly important to facilitate surgical procedure and reduce the number of complications. The objective of this video is to demonstrate pelvic neuroanatomic structures and their relationships in the pelvic sidewall and the presacral space in a laparoscopic cadaveric dissection. DESIGN: Case report (anatomic study). SETTING: Medical training center (AdventHealth Nicholson Center, Orlando, FL). INTERVENTIONS: The dissection started with the mobilization of the iliac vessels from the pelvic sidewall to identify the obturator nerve. The peritoneum of the ovarian fossa was opened, and the ureter was dissected up to the level of the uterine artery. The hypogastric nerve was identified. The close relationship between the ovarian fossa and the obturator nerve could be demonstrated. The deep dissection of the obturator fossa allowed for the identification of the lumbosacral trunk, S1, the sciatic nerve, S2, S3, S4, and the splanchnic nerves. Then, the ischial spine and the sacrospinous ligament were identified. The pudendal nerve and vessels could be observed passing below the sacrospinous ligament, entering the pudendal canal (Alcock's canal). The presacral space was dissected, and the hypogastric fascia was opened. S1 to S4 were identified coming from the sacral foramens. The laparoscopic dissection, using the cadaveric model, allowed for the development of the entire retroperitoneal anatomy, focusing on the dissection of the pelvic innervation. Anatomic relationships among the ureter, the hypogastric nerve, the uterosacral ligament, the splanchnic nerves, the inferior hypogastric plexus, and the organs (bowel, vagina, uterus, and bladder) could be demonstrated. CONCLUSION: A laparoscopic cadaveric dissection can be used as a resource to demonstrate and educate surgeons about the neurologic retroperitoneal structures and their relationships.

Bilateral ureteral endometriosis-an indolent, aggressive, and dangerous condition.

OBJECTIVE: To describe an unusual bilateral ureteral reimplantation due to endometriosis and to provide a flowchart of conservative decision making. DESIGN: Video description of a case, demonstrating a step-by-step explanation of the decision planning and description of the surgical steps in a female patient with bilateral ureteral endometriosis who had previously undergone operation for bowel endometriosis, and who presented with extensive disease in the posterior compartment with no symptoms besides bilateral renal function disruption. The study was reviewed and approved by the Hospital Beneficência Portuguesa de São Paulo Institutional Review Board. SETTING: Tertiary referral center. PATIENTS: Deep infiltrating endometriosis involving the ureter has an incidence of 0.1% to 1%, normally affecting the lower one-third of its segment, up to 4 cm above the vesicoureteric junction. Bilateral ureteral involvement occurs in 9% of cases. The absence of specific symptoms makes the diagnosis of this condition challenging. Lumbar pain develops when its involvement is complicated by marked obstruction with impaired renal function. Decompressive surgery is mandatory. The necessity of ureteroneocystostomy increases along with the severity of hydronephrosis, accounting for 62% of ureteral decompressive procedures. However, bilateral ureteroneocystostomy is a rare procedure, not exceeding 6% of ureteral reimplantations. This case illustrates a situation in which a patient with a previous bowel segmental resection presented with an advanced bilateral posterior deep infiltrating endometriosis, compromising the lower rectum below the previous anastomosis, vagina, posterior, and lateral parametrium bilaterally and both inferior hypogastric plexi. Hormonal therapy improved endometriosis symptoms but did not control the urinary tract involvement. Along with the patient, considering a high probability of intestinal, urinary, and sexual impairment, a conservative approach was chosen. INTERVENTION: The procedure started with adesiolysis, accessing the retroperitoneum and identifying both dilated ureters (Figs. 1 and 2). They were dissected as caudally as possible, until endometriosis fibrosis was reached, to have a bigger length of proximal ureter to allow a tension-free ureteroneocystostomy. The Retzius space was developed, and the bladder was freed and mobilized (Fig. 3). After cutting the ureter, the proximal end was spatulated. The bladder dome was approximated to the psoas muscle with an interrupted suture to permit a tension-free ureteroneocystostomy. The detrusor muscle was opened for approximately 2 to 3 cm, exposing the vesical mucosa, which was subsequently opened. The posterior ureterovesical anastomosis was performed with running monofilament absorbable 4-0 sutures. A double-J stent was placed, and the anterior ureterovesical anastomosis was completed. The detrusor muscle was loosely closed over the ureter with interrupted absorbable sutures to avoid urinary reflux. A Maryland clamp was used to ensure sufficient entry of the tunnel. All these steps were repeated in the contralateral side. MAIN OUTCOME MEASURE(S): Successful performance of a bilateral laparoscopy tension-free ureteroneocystostomy with bilateral psoas hitch. RESULTS: The postoperative course was uneventful. Renal function was restored. One year after surgery, the patient remained asymptomatic, and endometriotic lesions showed no increase, thus remaining stable. CONCLUSION: Ureteral endometriosis can be aggressive and indolent. Decompressive procedures must be performed. The decision-making process must take into consideration the patient's characteristics and expectations. In selected cases, a conservative approach may be required, when future possible functional disfunctions can be worse than the actual symptoms. In those situations, close surveillance is necessary.

Which Knots Are Recommended in Laparoscopic Surgery and How to Avoid Insecure Knots.

STUDY OBJECTIVE: To investigate why security of identical knot sequences is variable and how to avoid occasionally insecure knots. DESIGN: A factorial design was used to assess factors affecting the security of half knot (H) and half-hitch (S) knot combinations. The effect of tying forces and the risk factors to transform H knots into S knots were investigated. The risk factors evaluated were as follows: starting with an H1 or H2 instead of an H3 knot, inexperience, short sutures, and monomanual knot tying. Security of transformed knots, S2S1 and S2S2 knots, and their recuperation with 2 additional half hitches, SSb or SbSb, were evaluated. SETTING: Training center for laparoscopic suturing. PATIENTS: Not applicable. INTERVENTIONS: Security of knots was evaluated in vitro. MEASUREMENTS AND MAIN RESULTS: The forces that caused knot combinations to open before breaking of the suture were used to calculate the risk of opening with low forces. Tying more strongly increased the security of half knots (H2H1sH1s) (p <.02) and half hitches (p <.001). The forces needed to transform an H3 into an S3 are higher than those for an H2 (p <.001), and the risk increases when the surgeon is inexperienced (p <.001), when sutures are short (p <.001), and when monomanual knot tying (p <.001) is used. Inadvertently made S2S1 and S2S2 knots are dangerous, with the exception of the symmetric S2S2, which is stable. Unstable knots such as S2S1a and S2S2a knot combinations improve with 2 additional blocking half hitches (SbSb), but S2S2aSbSb remains occasionally insecure. CONCLUSION: To reduce the risk of accidentally transforming a first H into an S knot, it is recommended to start with an H3, tie with force, avoid short sutures, and use bimanual suturing. This permits the recommendation to use preferentially H3H2 knots or 5 half hitches (SSSbSbSb). When in doubt, half knot combinations should be secured with at least 2 blocking half hitches.

Surgical Principles for Disc Resection of Deep Bowel Endometriosis.

OBJECTIVE: Colorectal involvement represents 90% of bowel endometriosis. The best surgical approach must consider the patient's clinical symptoms, preoperative imaging, and correlation with surgical findings. For patients with severe pain who either have failed medical treatment or contraindications to hormonal treatment and have a single bowel lesion <3 cm that involves the inner muscularis, disc resection is the preferred approach to treat bowel endometriosis [1,2]. Therefore, here we describe the surgical principles for disc resection for deep bowel endometriosis. DESIGN: Step-by-step video illustration of our surgical technique with clarification of surgical principles. SETTING: Tertiary care center. INTERVENTION: A mechanical bowel preparation is given before surgery. A 10-mm port is placed in the umbilicus, and 3 other 5-mm auxiliary ports are placed in the right and left iliac fossa and in the suprapubic region. Dissection starts with development of both medial pararectal spaces. The retrocervical region is approached, and the bowel lesion is isolated. A suture is placed into the endometriosis bowel lesion to facilitate invagination into the stapler. A circular stapler is inserted into the rectum, and the anvil is opened at the level of the endometriosis lesion. Each end of the suture held by 2 graspers are pushed dorsally, whereas the stapling device is gently pushed ventrally, imbricating the delineated area. The stapler is closed, including the endometriosis area. After reassuring that the posterior part of the mesentery is free, the device is fired, excising only the anterior wall of the rectum. CONCLUSION: Disc resection is the technique of choice to treat a focal bowel endometriosis lesion <3 cm.

Extrapelvic Endometriosis: A Systematic Review.

OBJECTIVE: To conduct a systematic review of the literature on patients with extrapelvic deep endometriosis. DATA SOURCES: A thorough search of the PubMed/Medline, Embase, and Cochrane databases was performed. METHODS OF STUDY SELECTION: Studies in the last 20 years that reported on primary extrapelvic endometriosis were included (PROSPERO registration number CRD42019125370). TABULATION, INTEGRATION, AND RESULTS: The initial search identified 5465 articles, and 179 articles, mostly case reports and series, were included. A total of 230 parietal (PE), 43 visceral (VE), 628 thoracic (TE), 6 central nerve system, 12 extrapelvic muscle or nerve, and 1 nasal endometriosis articles were identified. Abdominal endometriosis was divided into PE and VE. PE lesions involved primary lesions of the abdominal wall, groin, and perineum. When present, symptoms included a palpable mass (99%), cyclic pain (71%) and cyclic bleeding (48%). Preoperative clinical suspicion was low, the use of tissue diagnosis was indeterminate (25%), and a few (8%) malignancies were suspected. Surgical treatment for PE included wide local excision (97%), with 5% recurrence and no complications. Patients with VE involving abdominal organs - kidneys, liver, pancreas, and biliary tract - were treated surgically (86%) with both conservative (51%) and radical resection (49%), with 15% recurrence and 2 major complications reported. In patients with TE involving the diaphragm, pleura, and lung, isolated and concomitant lesions occurred and favored the right side (80%). Patients with TE presented with the triad of catamenial pain, pneumothorax, and hemoptysis. Thoracoscopy with resection followed by pleurodesis was the most common procedure performed, with 29% recurrence. Adjuvant medical therapy with gonadotropin-releasing hormone was administered in 15% of cases. Preoperative magnetic resonance imaging was performed in all cases of nonthoracic and nonabdominal endometriosis. Common symptoms were paresthesia and cyclic pain with radiation. Surgical resection was reported in 84%, with improvement of symptoms. CONCLUSION: Extrapelvic endometriosis, traditionally thought to be rare, has been reported in a considerable number of cases. Heightened awareness and clinical suspicion of the disease and a multidisciplinary approach are recommended to achieve a prompt diagnosis and optimize patient outcomes. Currently, there are no comparative studies to provide recommendations regarding optimal diagnostic methods, treatment options, and outcomes for endometriosis involving extrapelvic sites.

What is the Best Surgeon's Knot? Evaluation of the Security of the Different Laparoscopic Knot Combinations.

STUDY OBJECTIVE: To investigate the security of various knot combinations in laparoscopic surgery. DESIGN: Prospective nonrandomized trial (Canadian Task Force classification II). SETTING: Storz Training Centre, Sao Paulo, Brazil. INTERVENTION: Different knot combinations (n = 2000) were performed in a laparoscopic trainer. Dry or wet 2.0 polyglycolic acid or dry 2-0 poliglecaprone 25 was used. The tails were cut at 10 mm, and the loops were tested in a dynamometer. The primary endpoints were the forces at which the knot combination opened or at which the suture broke. Resulting tail lengths were measured. MEASUREMENTS AND MAIN RESULTS: Surprisingly, the combination of a 2-throw half knot (H2) and a symmetric 1-throw half knot (H1s) (a surgical flat knot) opened at <1 Newton (N) in 2.5% of tests and at <10 N in 5% of tests. This occasional opening at low forces persisted after 1 or 2 additional H1s knots. A sequence of an H2 or a 3-throw half knot (H3) followed by a H2, either symmetric or asymmetric (H2H2 or H3H2), resulted in 100% secure knots that never opened at forces below 30 N. Other safe combinations were H2H1s followed by 2 blocking half hitches, and a sequence of 5 half hitches with 3 blocking sequences. CONCLUSION: A traditional surgical knot (H2H1s) occasionally opens with little force and thus is potentially dangerous. Safe knots are H2H2 and H3H2 combinations, a sequence of 5 half hitches with 3 blocking sequences, and H2H1s together with 2 blocking half hitches.

Different Blocking Sequences Performed by Laparoscopy.

STUDY OBJECTIVE: To demonstrate the application of different knot blocking sequences in laparoscopic surgery. DESIGN: A step-by-step demonstration of different blocking sequences performed by laparoscopic surgery (Canadian Task Force classification III). SETTING: Private hospital in Curitiba, Paraná, Brazil. INTERVENTION: The correct placement of one knot over the other is rarely taught in the surgical literature. Laparoscopic knot-tying techniques may be performed using one hand (monomanual technique) or alternating both hands (bimanual technique). Rotation of the needle holders around the thread (clockwise or counterclockwise rotation) is very important to have a symmetric or an asymmetric configuration of the knot, which affects the stability of the entire knot sequence. The monomanual knot-tying technique needs to alternate the rotation of the needle holder, and the bimanual technique does not when performing half knots (square or flat knots). The half hitch is an asymmetric knot that is obtained when the surgeon makes asymmetric traction on one thread (passive thread) and place the knot using the other thread (active thread). To block 2 half hitches, the surgeon needs to change the active and the passive threads. Beginners in laparoscopy commonly make mistakes tying knots, leading to an insecure knot sequence that may slip and/or open under minimal forces. In this video, we demonstrate different types of blocking sequences performed by laparoscopy applied in different surgical procedures. Ethics Committee approval was obtained for this video. CONCLUSION: Knot-tying is a basic surgical skill that must be mastered by all laparoscopists.

Quality of Life in Women with Endometriosis: An Integrative Review.

OBJECTIVE: The purpose of this study was to conduct an integrative review of the health-related quality of life (QoL) burden in women with endometriosis. MATERIALS AND METHODS: This integrative review was carried out by consulting the BIREME/MEDLINE databases through July 2017. We searched for articles published in the past 12 years using the MeSH terms "quality of life" and "endometriosis" and its representations in Portuguese and English. RESULTS: Database search yielded 367 records, and eight additional records were identified through other sources. After analyzing articles based on inclusion and exclusion criteria, rigor and methodological evidence, 26 publications constituted the final corpus of our analysis. Generic instruments most commonly used to assess QoL included the Short Form Health Survey (SF-36), World Health Organization Quality of Life Assessment-bref (WHOQOL-bref); the 12-item Short Form Health Survey (SF-12), and the Duke Health Profile, among others. Disease-specific questionnaires were also used, and two studies collected qualitative data. Endometriosis had a negative impact in all domains of QoL, which was more associated to symptoms than to the diagnosis per se. It also negatively affected sleep quality and perceived stress. Impact had age-related differences in most studies, and was not related to endometriosis staging. CONCLUSIONS: Endometriosis negatively affects QoL. A consensus must be reached as to which QoL instrument should be used to make studies comparable.

Caracterização morfológica da endometriose ovariana / Morphologic characterization of ovarian endometriosis

Introdução: De origem controversa e repercussões imprevisíveis, o acometimento ovariano pela endometriose é considerado importante marcador de extensão da doença, pois pode se associar a endometriose profunda. Inúmeras teorias etiopatogênicas tentam explicar a gênese da endometriose ovariana e, duas delas recentemente tem sido reativadas, como a da metaplasia celômica que justificaria o conceito atual de endometriose intra-ovariana profunda e a da menstruação retrógrada, que explica a origem tubárea dos endometriomas. Estima-se em 5% a 10% de câncer ovariano em lesões de endometriose de ovário; enquanto, a frequência total de transformação maligna foi estimada entre 0,3 a 2,5%. Objetivo: Avaliar as formas de apresentação da endometriose ovariana e possíveis associações com o quadro clínico, com outros locais de doença, com os marcadores de atividade proliferativa (Ki-67), com a expressão de alterações moleculares dos mecanismos apoptóticos consideradas importantes no processo de carcinogênese das lesões de endometriose (p53 e Bcl-2) e com os receptores de estrogênio (dependência hormonal). Métodos: Estudo de coorte retrospectivo exploratório, com 63 pacientes operadas entre 2002 a 2012, com diagnóstico de endometriose ovariana preenchendo os critérios de inclusão e exclusão. Os preparados histológicos foram reavaliados e reclassificados de acordo com o tipo histológico, com a forma de apresentação e com a presença de infiltração do parênquima ovariano, sendo divididas em endometriose ovariana peritoneal, cistica e intraparenquimatosa. Foram avaliados a expressão do Ki-67, do p53, do Bcl- 2 e dos receptores de estrogênio no epitélio e no estroma tecidual. As pacientes ainda foram avaliadas de acordo com os sintomas clínicos e locais concomitantes de doença. Resultados: A forma de apresentação da endometriose ovariana mais frequente foi a cística (72,2%), seguida pela intraparenquimatosa (22,2%) e pela forma peritoneal (5,6%). Todas podem...

Introduction: Of controversial origin and unpredictable repercussions, ovarian endometriosis is an important marker of disease extensiveness, as it may be related to deep infiltrating endometriosis. Numerous theories try to explain its origin, but two of them have been recently reactivated, such as celomic metaplasia, which would justify the concept of deep ovarian endometriosis, and retrograde menstruation, which can explain the tubal origin of ovarian endometriosis. It is estimated 5% to 10% of ovarian cancer in ovarian endometriosis, but malignant transformation may occur in 0.3 to 2.5% of the cases. Objective: Identify the presenting forms of ovarian endometrisosis and its possible relations to clinical symptoms, to other sites of disease, to proliferative activity markers (Ki-67), to the molecular expression of apoptotic mechanisms, considered important to the process of malignant transformation (p53 and Bcl-2) and to estrogen receptors (hormonal dependency). Methods: This is a retrospective exploratory cohort study, done between 2002 and 2012, including 63 women with laparoscopic diagnosis of ovarian endometriosis which fullfilled inclusion and exclusion criteria. The histologic specimens were reanalysed and reclassified according to the histologic pattern, to its presenting form and to the presence of parenchyma infiltration. The expression of Ki-67, p53, Bcl-2 and estrogen receptors were evaluated in the tissue epithelium and stroma. Clinical symptoms and concomitant sites of disease were also evaluated. Results: The most frequent form of ovarian endometriosis was cystic (72.2%), followed by intra-parenchymatous (22.2%) and peritoneal (5.6%). All of them can be infiltrative. The prevalence of infiltrative ovarian endometriosis was 30.5%. No association were found between symptoms, anatomical distribution of disease, markers expression and the presenting forms of ovarian endometriosis as well as adjacent parenchymal infiltration. Conclusion:...

CD4(+) CD25(high) Foxp3(+) cells increased in the peritoneal fluid of patients with endometriosis.

PROBLEM: To evaluate CD4(+) CD25(high) Foxp3(+) cells and IL-6, IL-10, IL-17, and TGF-ß in the peritoneal fluid of women with endometriosis. METHOD OF STUDY: A total of ninety-eight patients were studied: endometriosis (n = 70) and control (n = 28). First, peritoneal fluid lymphocytes were isolated, and CD4(+) CD25(high) cells were identified using flow cytometry. Then, RT-PCR was performed to verify Foxp3 expression in these cells. Also, IL-6, IL-10, IL-17, and TGF-ß concentration was determined. RESULTS: Of all the lymphocytes in the peritoneal fluid of women with endometriosis, 36.5% (median) were CD4(+) CD25(high) compared to only 1.15% (median) in the control group (P < 0.001). Foxp3 expression was similarly elevated in patients with the disease compared to those without (median, 50 versus 5; P < 0.001). IL-6 and TGF-ß were higher in endometriosis group (IL-6: 327.5 pg/mL versus 195.5 pg/mL; TGF-ß: 340 pg/mL versus 171.5 pg/mL; both P < 0.001). IL-10 and IL-17 showed no significant differences between the two groups. CONCLUSION: The peritoneal fluid of patients with endometriosis had a higher percentage of CD4(+) CD25(high) Foxp3(+) cells and also higher levels of IL-6 and TGF-ß compared to women without the disease. These findings suggest that CD4(+) CD25(high) Foxp3(+) cells may play a role in the pathogenesis of endometriosis.

Oxidative stress biomarkers in patients with endometriosis: systematic review.

PURPOSE: Since the first description about oxygen toxicity made by Joseph Priestley, the oxidative stress has been enrolled as a key factor in the pathogenesis of endometriosis. Our aim was to review oxidative stress biomarkers measured in patients with endometriosis. METHODS: Relevant studies were identified by searches of the MEDLINE database from 1990 to March 2011 using endometriosis, free radical and oxidative stress as mesh terms. We only included manuscripts in English, and review articles were excluded. In addition, free radical chemistry and oxidative stress history were discussed. RESULTS: After inclusion and exclusion criteria, 19 articles were selected to be included in this systematic review. A total of 36 oxidative stress biomarkers (20 different markers) were measured in patients with endometriosis. Some of the markers were measured in more than one manuscript. They were arranged in five subgroups: Enzymatic activity (n = 3), Anions/free radicals (n = 5), Lipoperoxidation markers (n = 7), DNA Damage markers (n = 1), and Protein oxidation (n = 4). Of those 36 markers, 23 were found to be significantly higher in patients with endometriosis comparing with control patients. CONCLUSION: Oxidative stress plays an important role in the pathogenesis and progression of endometriosis.