Surgical variance between postconceptional and preconceptional minimally invasive transabdominal cerclage placement.

Recent data show that transabdominal cerclage placement via laparoscopy carries better obstetrical outcomes in comparison to transabdominal cerclage placement via laparotomy. In this surgical tutorial, we review the technique for minimally invasive abdominal cerclage and highlight the surgical differences between preconceptional and conceptional cerclage.

Correction to: Two-port robotic hysterectomy: a novel approach.

The objective of the study was to demonstrate a novel technique for two-port robotic hysterectomy with a particular focus on the challenging portions of the procedure. The study is designed as a technical video, showing step-by-step a two-port robotic hysterectomy approach.

Multidisciplinary Resection of Deeply Infiltrative Endometriosis.

STUDY OBJECTIVE: To describe a multidisciplinary approach for the resection of deeply infiltrative endometriosis using the robotic platform. DESIGN: A technical video showing a step-by-step approach for the resection of deeply infiltrative endometriosis (Canadian Task Force classification level III). Institutional review board approval was not required for this study. SETTING: There is considerable involvement of the bowel and bladder with deeply infiltrative endometriosis [1-3]. The need for operative procedures involving multiple organs while performing a complete resection is common. The benefits of minimally invasive surgery for a gynecologic pathology have been documented in numerous studies. Patients had fewer medical and surgical complications postoperatively, better cosmesis, and better quality of life [4-6]. We believe that deeply infiltrative endometriosis does not preclude patients from having a minimally invasive resection procedure. In this video, we describe how the robotic platform was used for a seamless transition between surgical specialties including gynecology, colorectal, and urology to ensure complete resection of endometriosis lesions involving multiple organs. PATIENT: A 47-year-old woman with a 4-year history of severe pelvic pain, dysuria, dyspareunia, dyschezia, and dysmenorrhea failing multiple medical therapies presented to our clinic to discuss surgical options. After thorough counseling, the decision was made to proceed with definitive surgical management. Postoperatively, the patient was admitted for 2 days of postoperative inpatient care. After meeting all immediate postoperative milestones, she was discharged with an indwelling Foley catheter and instructed to follow up in the clinic with all 3 surgical specialties. At the 1-week interval, she was seen by the urology team; her indwelling catheter was removed after a cystoscopy was performed documenting adequate healing. Two weeks postoperatively, the patient was seen by the gynecology and colorectal teams and was noted to be healing adequately from the procedure. Her six-week visit was also unremarkable. She continued to follow up with the gynecology team for her yearly well-woman examinations and has been symptom free for 2 years after the surgery. She takes norethindrone daily to minimize recurrence. INTERVENTIONS: Preoperative pelvic magnetic resonance imaging (MRI) showed bladder endometriosis and extensive rectovaginal endometriosis. We describe the multidisciplinary approach used for surgery and the procedures performed by each specialty. The urology team performed a cystoscopy preoperatively to assess for full-thickness erosions and the location of those lesions in that event. The urology team also reviewed the magnetic resonance images with the radiology team, and the endometriosis lesions were suspected to be close to the bladder trigone, keeping in mind that this finding could be overestimated given that the bladder was deflated at the time the imaging was obtained. Accordingly, at the time of surgery, the decision was made to proceed with cystoscopy and the placement of ureteral stents as a prophylactic measure. An intentional cystotomy and resection of the bladder section involved with endometriosis were performed followed by watertight closure. The trigone area of the bladder was not involved, and ureteral reimplantation was not needed in this case. The gynecology team operated second and performed an extensive dissection of the retroperitoneal space with the development of the pararectal and paravesical spaces. They also ligated the uterine artery at its origin followed by dissection of the uterovesical space, effectively reflecting the bladder off of the lower uterine segment. At this point, they proceeded with a total hysterectomy, and the specimen was removed from the pelvis through the vaginal cuff. Preoperatively, the colorectal surgeon ordered a colonoscopy to determine if full-thickness erosions were present and reviewed the magnetic resonance images with the radiology team. Based on the MRI and colonoscopy, all patients are counseled and consented for the possibility of a low anterior resection and loop ileostomy to protect the anastomosis. Based on the understanding that colorectal and gynecologic surgeries have a different approach when dissecting the pararectal space at our institution, a discussion between the 2 teams is initiated at the multidisciplinary session for surgery planning. In the case we present, the colorectal surgeon opted for the removal of the uterus before his dissection was initiated given that he dissects this space presacrally and not retroperitoneally like the gynecology counterpart. He would also benefit from the extra space for dissection with the uterus out of the pelvis. The colorectal part of the case was initiated by mobilization of the rectum and dissecting the obliterated rectovaginal space. The presacral space was then opened followed by mobilization of the rectosigmoid from its attachment. The case was concluded with full transection and reanastomosis of the rectum section involved with endometriosis. The specimen was also removed from the pelvis through the vaginal cuff. MEASUREMENTS AND MAIN RESULTS: Complete resection of deeply infiltrative endometriosis spanning beyond the scope of 1 surgical specialty. No immediate intraoperative, perioperative, or long-term complications from surgery. Complete resolution of endometriosis symptoms. CONCLUSION: We encourage collaborative care for planning and performing comprehensive and safe resection of deeply infiltrative endometriosis.

Systematic Review of Transabdominal Cerclage Placed via Laparoscopy for the Prevention of Preterm Birth.

Preterm birth is the leading cause of neonatal mortality and morbidity. Multiple interventions are available to minimize this occurrence; however, despite current recommendations including medical management, cervical length screening, and transvaginal cerclage, a substantial number of women still experience preterm birth. For those patients, experts recommend transabdominal cerclage (TAC). In this systematic review, we compared 26 studies (1116 patients) of TAC placed via laparotomy (TAC-lap) and 15 studies (728 patients) of TAC placed via laparoscopy (TAC-lsc). There was no significant difference in overall neonatal survival between the TAC-lsc and TAC-lap groups (89.9% vs 90.8%, respectively; p = .80). When T1 losses were excluded, the neonatal survival rate was significantly higher for the TAC-lsc group (96.5% vs 90.1%; p < .01). In terms of obstetrical outcomes, the TAC-lsc group had a higher rate of deliveries at gestational age (GA) > 34 weeks (82.9% vs 76%; p < .01) and a lower rate of deliveries at GA 23.0 to 33.6 weeks (6.8% vs 14.8%; p < .01). The TAC-lsc group also had fewer T2 losses (3.2% vs 7.8%; p < .01). TAC-lsc offers all the benefits of minimally invasive surgery with better obstetrical outcomes compared with TAC-lap.

Determining the Effect of External Stressors on Laparoscopic Skills and Performance Between Obstetrics and Gynecology Residents.

STUDY OBJECTIVE: To evaluate the effect of stress on laparoscopic skills between obstetrics and gynecology residents. DESIGN: Observational prospective cohort study. DESIGN CLASSIFICATION: Prospective cohort. SETTING: Urban teaching university hospital. PARTICIPANTS (PATIENTS): Thirty-one obstetrics and gynecology residents, postgraduate years 1 to 4. INTERVENTION: We assessed 4 basic laparoscopic skills at 2 sessions. The first session was the baseline; 6 months later the same skills were assessed under audiovisual stressors. We compared the effect of stress on accuracy and efficiency between the 2 sessions. MEASUREMENTS AND MAIN RESULTS: A linear model was used to analyze time. Under stress, residents were more efficient in 3 of the 4 modules. Ring transfer (hand-eye coordination and bimanual dexterity), p = 0.0304. Ring of fire (bimanual dexterity and measure of depth perception), p = 0.0024 and dissection glove (respect of delicate tissue planes), p = 0.0002. Poisson regression was used to analyze the total number of penalties. Residents were more likely to acquire penalties under stress. Ring transfer, p = 0.0184 and cobra (hand-to-hand coordination), p = 0.0487 yielded a statistically significant increase in penalties in the presence of stressors. Dissection glove p = 0.0605 yielded a nonsignificant increase in penalties. CONCLUSION: Our work confirmed that while under stress residents were more efficient, this translated into their ability to complete tasks faster in all the tested skills. Efficiency, however, came at the expense of accuracy.

Comparison of cost and operative outcomes of robotic hysterectomy compared to laparoscopic hysterectomy across different uterine weights.

Operative cost and outcomes between robotic and laparoscopic hysterectomy across different uterine weights. Retrospective cohort study including patients undergoing robotic and laparoscopic hysterectomy for benign disease at an Academic university hospital. One hundred and ninety six hysterectomies were identified (101 robotic versus 95 laparoscopic). Demographic and surgical characteristics were statistically equivalent. Robotic group had a higher body mass index (±SD) (32.9 ± 6.5 versus 30.4 ± 7.1, p 0.012) and more frequent history of adnexal surgery (12.9 versus 4.2%, p 0.031). Laparoscopic group had a higher number of concurrent salpingectomy (81 versus 66.3%, p 0.02). Estimated blood loss did not differ between procedures. Compared to robotic hysterectomies, laparoscopic procedures added 47 min (CI: 31-63 min; p < 0.001) of operative time, costed $1648 more (CI: 500-2797; p = 0. 005) and had triple the odds of having an overnight admission (OR = 2.94 CI: 1.34-6.44; p = 0.007). After stratification of cases by uterine weight, the mean operative time difference between the two groups in uteri between 750 and 1000 g and in uteri >1000 g was 81.3 min (CI: 51.3-111.3, p < 0.0001) and 70 min (CI: 26-114, p < 0.005), respectively, in favor of the robotic group. Mean direct cost difference in uteri between 750 and 1000 g and uteri >1000 g was 1859$ (CI: 629-3090, p < 0.006) and 4509$ (CI: 377-8641, p < 0.004), respectively, also in favor of the robotic group. In expert hands, robotic hysterectomy for uteri weighing more than 750 g may be associated with shorter operative time and improved cost profile.

Magnetic resonance imaging correlation to intraoperative findings of deeply infiltrative endometriosis.

OBJECTIVE: To show characteristics of deeply infiltrative endometriosis (DIE) on magnetic resonance imaging (MRI) and how they correlate with intraoperative findings. DESIGN: Overview of still and dynamic MRI images of four different patients with DIE. We then used videos from their surgeries to highlight the appearance of endometriosis corresponding to these images (educational video). SETTING: University hospital. PATIENT(S): Four different patients with DIE were included in this video. These were all women of reproductive age who suffered from debilitating deeply infiltrative endometriosis. These patients had a pelvic MRI performed at our institution and subsequently underwent surgery with one of our minimally invasive gynecologic surgeons. INTERVENTION(S): The MRI endometriosis protocol includes T1-weighted fat and nonfat saturated as well as T2-weighted sequences. Images are taken along all three planes (axial, sagittal, and coronal) before and after contrast. What distinguishes the standard MRI from the endometriosis-protocol MRI is the thickness of the slices taken. For the evaluation of endometriosis, T1 nonfat saturated images are taken in 6-mm slices with no skip sections in between. Then, T1 fat saturated images and T2-weighted images are taken in 5-mm slices with a 1-mm skip section in between slices. The areas that are suspicious for lesions consistent with DIE are corroborated on videos taken during surgery. MAIN OUTCOME MEASURE(S): Value of accurate mapping of lesions with the use of preoperative MRI in surgical planning and complete resection of diseased tissue. RESULT(S): Results from a previously published prospective study by Bazot et al. reported sensitivity, specificity, positive predictive value, and negative predictive value of 90.3%, 91%, 92.1%, and 89%, respectively. Similarly to our institution, that study used a 1.5-T MRI, and the protocol of our institution closely mimicked the technique used in that study. Another prospective study published by Hottat et al. showed sensitivity, specificity, and positive and negative predictive values of MRI predicting intraoperative disease of 96.3%, 100%, 100%, and 93.3% respectively. Those results were gathered with the use of a 3.0-T MRI. The high accuracy in these studies of prediction of deep pelvic endometriosis in specific locations shows that MRI is effective for preoperative planning, as was the case for the four patients in our video. CONCLUSION(S): Preoperative planning for DIE with the use of MRI is integral in surgical planning. Other imaging modalities to diagnose DIE, such as transvaginal ultrasound, endoanal ultrasound, barium enema, cystoscopy, and rectoscopy, have all been used and studied for the evaluation of endometriosis. However, given its accuracy for mapping lesions, MRI could potentially replace multiple types of imaging while offering the best option for preoperative planning. Accurate mapping would result in greater success of resection and allow for multidisciplinary planning if necessary. Furthermore, being able to train the eye to identify lesions on MRI that are consistent with DIE is an asset to the gynecologic surgeon.

Urethral Solitary Fibrous Tumor: A Rare Pathologic Diagnosis of a Periurethral Mass.

Solitary fibrous tumors (SFTs) may occur at any site in the body. SFTs can only be conclusively diagnosed based on histopathologic and immunohistochemical characteristics of the tumor. The presence of SFTs in the abdomen and pelvis is extremely rare. To our knowledge no cases of urethral solitary fibrous tumor in the literature have been reported so far. We present a case of a solitary fibrous tumor arising from the urethra in a twenty-three-year-old female presenting with vaginal mass.

Spontaneous Bilateral Ectopic Pregnancy: A Case-Report.

BACKGROUND: Bilateral tubal pregnancies in the absence of preceding induction of ovulation are rare. They are usually diagnosed at the time of surgery. CASE: We report a case of spontaneous bilateral tubal pregnancies diagnosed intraoperatively. A 28-year-old primigravida presented with light vaginal bleeding and abdominal pain 6 weeks after her last menstrual period. Her ß-hCG level was 8,240 mIU/mL. Ultrasonography showed evidence of right tubal ectopic pregnancy. Laparoscopy revealed the presence of a simultaneous left tubal ectopic pregnancy. A bilateral laparoscopic salpingectomy was performed without complications, and the pathology report confirmed the diagnosis. CONCLUSION: The diagnosis of bilateral tubal pregnancy is usually made intraoperatively, thus highlighting the importance of closely examining both tubes at the time of surgery, even in the presence of significant adhesive disease.

Abdominal Approaches to Tissue Containment and Extraction in Minimally Invasive Gynecologic Surgery.

STUDY OBJECTIVE: To show different abdominal methods of tissue containment and specimen extraction techniques as an alternative to electromechanical morcellation (EMM). DESIGN: A stepwise surgical tutorial using a narrated video (Canadian Task Force classification III). SETTING: An academic tertiary care hospital. INTERVENTIONS: Minimally invasive gynecologic surgery requires the extraction of large tissue specimens through small incisions. EMM was largely used until recently when the Food and Drug Administration issued a statement on its safety. In this video, we present alternative techniques to EMM as well as different methods of tissue containment. Uteri specimens are contained using a 3M Steri-Drape isolation bag (3M Healthcare, Maplewood, MN) and, alternatively, the Alexis Containment Extraction System (Applied Medical, Rancho Santa Margarita, CA). The contained specimen is manually extracted through the 2.5-cm umbilical port incision using the paper roll technique described here. CONCLUSION: These techniques for tissue containment and extraction provide an alternative to EMM. They allow the minimally invasive surgeon to contain and retrieve large specimens. When used appropriately, these techniques can decrease conversion rates to open abdominal surgery. They are easily reproducible with a minimal learning curve.

Robotic Cerclage in Advanced-stage Endometriosis.

STUDY OBJECTIVE: To show a stepwise surgical technique of robotic-assisted transabdominal cerclage placement in a patient with deeply infiltrative endometriosis. DESIGN: A step-by-step surgical tutorial using narrated video. SETTING: The George Washington University Hospital. Local institutional review board approval is not required for case reports (Canadian Task Force Classification III). PATIENTS: A 38-year-old woman with cervical incompetence and a history of infertility with 5 pregnancies accomplished by in vitro fertilization. Pregnancies were as follows: 3 first trimester losses, 1 second trimester loss, and another second trimester loss despite McDonald cerclage placement. INTERVENTIONS: Indications for transabdominal cerclage placement include a congenital short or amputated cervix, cervical scarring that would prevent a transvaginal approach, and failed prior vaginal cerclage [1]. Robotic-assisted abdominal cerclage placement was performed in a case of advanced rectovaginal endometriosis. Normal anatomy was restored; however, no excision of endometriosis was performed because the patient was asymptomatic and already undergoing in vitro fertilization for infertility. The procedure used a 12-mm camera port through the umbilicus, 2 ancillary 8-mm robotic ports, and a 5-mm assistant port; »-inch-width Mersilene tape (Ethicon, Somerville, NJ) was preloaded in the abdomen through the 12-mm port before docking. Survey of the pelvis revealed the presence of advanced rectovaginal endometriosis hindering visualization of the cervicouterine isthmi on the posterior side of the uterus. The preloaded needle was parked on the right parietal peritoneum. Before cerclage placement, retroperitoneal spaces dissection bilaterally was necessary to lateralize the ureters and mobilize the rectum away from the cervicovaginal junction where the cerclage would be placed. Anteriorly, the vesicouterine peritoneum was dissected transversely, and the bladder was dissected off the lower uterine segment. A window was created in the posterior leaf of the right broad ligament lateral to the cervicouterine junction and medial to the ureter. The uterine vessels were then skeletonized, and the needle was placed through the lateral cervical isthmus medial to the vascular bundle going posterior to anterior. The procedure was repeated on the contralateral side with the needle going in the anteroposterior direction. The tape was pulled tightly against the anterior cervical isthmus. The tape ends were tied together posteriorly. There was minimal blood loss with no complications. CONCLUSION: A robotic-assisted abdominal cerclage can be performed safely and effectively in patients with advanced-stage endometriosis.

Tips and Tricks: Single-Site Robotic-Assisted Myomectomy.

STUDY OBJECTIVE: To describe some tips and tricks that facilitate a single-site robotic- assisted (RA) myomectomy. DESIGN: Stepwise surgical tutorial using a narrated video (Canadian Task Force classification III). SETTING: Academic tertiary care hospital. INTERVENTIONS: Single-incision RA myomectomy is a novel technique that presents unique surgical challenges. Although similar in outcomes to multiport myomectomy, single-site myomectomy is more cosmetically appealing. Traditional laparoscopic single- site myomectomy has been associated with a steep learning curve. The robotic single-site platform mitigates some of these difficulties, which allows for the reproducibility and safety of this technique in appropriately selected patients. In this surgical tutorial, we present a case of a 7-cm type 2-5 fibroid removed with this approach. CONCLUSION: Single-site RA myomectomy is a safe, minimally invasive option for appropriately selected patients. Although it is a challenging procedure, it provides excellent cosmesis and is reproducible with adequate training and expertise.

A Case of Recurrent Rudimentary Horn Ectopic Pregnancies Managed by Methotrexate Therapy and Laparoscopic Excision of the Rudimentary Horn.

This report presents a case of a 31-year-old woman successfully treated medically for a noncommunicating rudimentary horn ectopic pregnancy who presented with a second, successive rudimentary horn pregnancy. Patient underwent laparoscopic excision of right rudimentary horn and right salpingectomy after failed methotrexate therapy. Given the potential for rupture and recurrence, serious efforts should be made to excise a uterine rudimentary horn.

Comparison of methods of morcellation: manual versus power.

INTRODUCTION: With the growing controversy surrounding power morcellation (PM), other approaches must be examined so that women may still benefit from minimally invasive gynecologic surgeries. In this study we sought to compare power morcellation to manual morcellation through mini-laparotomy or vaginally. MATERIALS AND METHODS: Retrospective cohort study carried out at an urban teaching hospital including 274 women who underwent a minimally invasive myomectomy or hysterectomy, requiring morcellation for tissue extraction. Surgical outcomes were compared between PM, manual morcellation through mini-laparotomy (MMM) and manual morcellation through the vagina (MMV). Primary outcome measured was operative time. Secondary outcomes were intraoperative and postoperative complications. RESULTS: Compared with PM, MMM was associated with shorter operative time for hysterectomy, (140.5 min vs. 164.2 min, p = 0.05). Intraoperative and postoperative complications were similar among groups. There were four postoperative complications in the MMV group, one related to blood transfusion and three related to postoperative vaginal cuff and pelvic infections. CONCLUSION: Compared with PM, MMM is associated with shorter operative time during hysterectomies. Intraoperative and postoperative complications were similar among groups.