Hysteroscopic morcellator to overcome cervical stenosis.

OBJECTIVE: To report a step-by-step technique to using a hysteroscopic morcellator to safely gain access into the intrauterine cavity in two patients with severe cervical stenosis and concomitant intrauterine pathology. DESIGN: Video article introducing the hysteroscopic morcellator for overcoming severe cervical stenosis. SETTING: Academic-based practice. PATIENT(S): A 36-year-old G0 female with primary infertility and uterine polyps and a 34-year-old G0 female with uterine polyps and a difficult trial transfer before undergoing an IVF cycle. In both patients, preoperative saline-infused sonography revealed submucosal filling defects and severe cervical stenosis. INTERVENTION(S): A hysteroscopic technique using the Hologic Myosure to overcome severe cervical stenosis with or without the use of intraoperative ultrasound. MAIN OUTCOME MEASURE(S): Despite using preoperative Cytotec, cervical stenosis was identified. Under direct visualization, a 4-mm Myosure XL blade was placed through a 7.25-mm Myosure XL hysteroscopy. The cutter blade, powered by an electromechanical drive system, enables simultaneous rotation and reciprocation. The blade allows one to shave and remove tissue and is applied to cervical stenosis, allowing safe access into the intrauterine cavity. RESULT(S): The intrauterine hysteroscopic Myosure morcellator allowed for safe and direct entry into the uterine cavity. We have since applied this technique to all patients where cervical stenosis is identified and have minimized potential uterine perforation and false tracks in our patients. CONCLUSION(S): Our technique is an alternative method for overcoming severe cervical stenosis and minimizing potential intraoperative complications.

Metroplasty to treat chronic pelvic pain resulting from outflow tract müllerian anomalies.

Chronic pelvic pain can result from noncommunicating uterine cavities in patients with müllerian anomalies. Traditional management has been to resect the noncommunicating uterine horn. Two cases are described. One had a unicornuate uterus with noncommunicating left uterine horn (American Fertility Society [AFS] classification IIb) and the other had a normal external uterine contour with noncommunicating left uterine cavity that did not fit any category of the AFS classification of müllerian anomalies. Attempts at connecting the noncommunicating cavities hysteroscopically failed in both cases. Successful unification of the cavities was subsequently achieved in the first case using the classic Strassman metroplasty with the assistance of the robot. The unification of uterine cavities was achieved using a modified Strassman metroplasty in the second patient, as there was no uterine horn for landmark. Robot assistance was utilized in this case as well. Both patients are symptom free after surgery. We conclude that laparoscopic Strassman metroplasty, with or without robot assistance, is a viable alternative to resection of uterine horns in patients with hematometra, chronic pelvic pain, and noncommunicating uterine cavities.

Contained morcellation using the GelPOINT advance access platforms and 3M Steri-Drape endobag.

OBJECTIVE: To report a technique that safely allows power and hand morcellation for laparoscopic hysterectomy and myomectomy specimens in a contained fashion in the event of unsuspected uterine sarcoma or leiomyosarcoma. DESIGN: Video article introducing a method for enclosed tissue morcellation for laparoscopic specimens. SETTING: Hospital of an academic-based practice. PATIENT(S): Two patients underwent laparoscopic hysterectomy: a 57-year-old G7 P5025 female for leiomyoma, anemia, and a history of CIN-3; and a 38-year-old G0P0 female with a 10-year history of pelvic pain and severe dysmenorrhea who failed medical therapy. INTERVENTION(S): A technique using the GelPOINT Platform incision extender system and GelSeal Cap (GSP) Advanced Access Platform and a 50 cm × 50 cm 3M Steri-Drape endobag for enclosed intracorporeal and extracorporeal tissue morcellation of laparoscopic specimens. MAIN OUTCOME MEASURE(S): For training purposes, we used a pelvic simulator and cadaver to describe the step-by-step process and troubleshoot issues to optimize intra- and extracorporeal morcellation. This allowed for easier implementation on the live patient. RESULT(S): Simulation training and the cadaver model provided a learning platform for contained internal power and external hand morcellation, accelerating the learning curve in its application to the live patient. CONCLUSION(S): The GSP and 3M Steri-Drape endobag is an alternative for laparoscopic power or hand morcellation. Using simulation training helped transition this technique to the live patient, allowing for easy and safe removal of tissue specimens and minimizing the potential for tissue seeding and dissemination.