Preserving Fertility by Treating the 3 Compartments: Laparoscopic Approach to Deep Infiltrating Endometriosis.

STUDY OBJECTIVE: To describe a laparoscopic technique for the resection of deep endometriosis, treating the 3 compartments. DESIGN: Educational video. SETTING: Tertiary referral center in Strasbourg, France PATIENT: A 37-year-old primiparous woman. INTERVENTION: Adenomyomectomy, partial cystectomy, and bowel resection. Fertility preservation was mandatory because of the patient's desire for future pregnancy. MEASUREMENTS AND MAIN RESULTS: A 37-year-old primiparous woman presented with main symptoms of dysmenorrhea and dyspareunia associated with pollakiuria and macroscopic menstrual hematuria (with emission of endometriotic tissue on analysis). She also complained of dyschezia. Magnetic resonance imaging revealed an endometriotic nodule in the vesicouterine space with an involvement of the anterior wall of the uterus and a suspicion of bladder adenomyosis. There were lateral spicules attracting the ovaries toward the midline and an infiltration of the round ligaments and nodules related to the rectovaginal space's endometriosis. A possible invasion was noted underneath the rectal mucosa. The patient expressed her desire preserve fertility. The local institutional review board has approved the video. Initially, an ultrasonography was performed showing the adenomyoma invading the bladder. The second step was a cystoscopic evaluation by means of a double J probe and a bladder catheter. After surgery the bladder catheter was left in place for 15 days and the double J stents for 6 weeks. The first step was the dissection of the vesicouterine space to dissect the anterior adenomyoma from the bladder. A partial cystectomy was then performed to remove the bladder nodule. The adenomyoma was resected at its uterine portion and the uterus sutured. Surgery was then performed in the posterior compartment. Ureterolysis was performed bilaterally, and the pararectal fossas were then opened. The rectovaginal space was dissected. A rectosigmoid resection was mandatory to remove the bowel nodule. Patient follow-up included regular consultations and a hysterosonography at 6 weeks after surgery. Hysterosonography demonstrated an adequate patency. No adhesions to the uterus were found. We recommended to wait for 6 months to allow pregnancy according to the department's protocols. A clinical improvement was observed. Today, at 8 months she has not attempted pregnancy. CONCLUSIONS: A complete surgery is feasible for severe and deep endometriosis with a multicompartmental disease, using a laparoscopic approach aiming to preserve fertility.

Transvaginal Resection of an Infected Sacrocolpopexy Mesh by Single-Port Trocar.

STUDY OBJECTIVE: Laparoscopy using a single port improves morbidity while keeping the same level of requirement. This technique has been evaluated in gynecology for salpingectomy, ovarian surgery, and hysterectomy. Here, the authors illustrate a new use of a single port using the transvaginal approach. DESIGN: Case report (Canadian Task Force classification III). SETTING: Tertiary referral center in Strasbourg, France. PATIENT: Woman age 59 years. INTERVENTION: Single-port platform used in the transvaginal approach for resection of sacrocolpopexy mesh. The local institutional review board approved the video. MEASUREMENTS AND MAIN RESULTS: A 59-year-old woman suffering from insulin-dependent diabetes and a tobacco user had 2 laparoscopic sacrocolpopexies for recurrent rectocele, the first in 2007 and the second in 2012. The sequences were marked by mesh erosion and granuloma in the vagina, requiring its surgical excision in 2016. The patient was then symptomatic, with an increasingly foul-smelling vaginal discharge with recurrent mesh erosion. Magnetic resonance imaging showed an abscess formation along the length of the mesh to the promontory. The patient then underwent surgery, realized under probabilistic antibiotic therapy, consisting of complete excision of the sacrocolpopexy mesh by the transvaginal approach. After putting the single-port trocar (GelPoint; Applied Medical, Rancho Santa Margarita, CA) into the vagina and obtaining distension with the insufflator (AirSeal; Conmed, Utica, NY), classic laparoscopic instruments were introduced by the single-port trocar. The mesh was entirely resected in the retroperitoneal space. Mesh was again used because the exposed space is almost always surrounded by loose granulation tissue that facilitates dissection and also prevents injury to adjacent structures such as bladder, rectum, and peritoneum. Moreover, the opening of adjacent structures will manifest gas leaks and, consequently, loss of the pneumovagina. At the end of procedure, the vagina is not closed to permit optimal drainage with a multitubular drain in the dissection space. The surgery lasted 60 minutes. The mesh excision was completed with relative ease, and there was no blood loss. Bacteriologic examination revealed the presence of Streptococcus anginosus, Klebsiella pneumoniae, and Bacteroides fragili. The operating suites were simple with great cicatrization after 6 weeks. The principal difficulties of this surgery were obtaining a good seal by the creation of cutaneous sutures. Finally, there are less conflicts between the instruments inside the single-port trocar used in transvaginally because of a more limited dissection space. Indeed, the rate of mesh erosion reached 2.4% and, in case of infection, justifies this excision. CONCLUSION: The transvaginal use of a single-port trocar represents a good alternative, allowing easy resection of the sacrocolpopexy mesh while remaining in the retroperitoneal space.

Retroperitoneal Lumboaortic Lymphadenectomy Using a Vessel-Sealing Device in 10 Steps.

STUDY OBJECTIVE: Lumboaortic lymphadenectomy is frequently performed in the surgical management of different gynecologic pelvic malignancies: cervical endometrial and ovarian cancer. The retroperitoneal access presents a real advantage, allowing direct access to vascular axes, thus avoiding bowel segments. The use of a vessel-sealing device could facilitate the technique by providing an ergonomic alternative to conventional tools such as a bipolar grasper and scissors. Here the surgical technique of laparoscopic retroperitoneal lumboaortic lymphadenectomy using a vessel-sealing device in 10 steps is described. DESIGN: Educative video (Canadian Task Force classification III). SETTING: Tertiary referral center in Strasbourg, France. PATIENTS: Women undergoing lumboaortic lymphadenectomy. INTERVENTION: Laparoscopic retroperitoneal lumboaortic lymphadenectomy using a vessel-sealing device. The local institutional review board approved the video. MEASUREMENTS AND MAIN RESULTS: The surgeon and assistant are positioned on the left of the patient and the column is placed in front. After peritoneal exploration 3 trocars are introduced in the left flank according to a very precise arrangement. We use a camera scope with a zero-degree view angle. After development of the extraperitoneal space and identification of the vascular landmarks, lymphadenectomy using a vessel-sealing device involves several steps in an anticlockwise direction starting from the left common iliac group. We first start with the lateroaortic group of lymph nodes. We then continue with the preaortic, interaorticocaval, and precaval supramesenteric group. After that, we perform the inframesenteric dissection of lymph nodes, the bifurcation of the aorta, and finally the right common iliac group. At the end of the procedure, in the absence of signs of metastatic lymph nodes, we open the peritoneum. CONCLUSION: Retroperitoneal lumboaortic lymphadenectomy using a vessel-sealing device is useful because of better ergonomics of the multitasking instrument, avoiding alternating between scissors and bipolar forceps. The surgeon will be able to use both hands for exposure and for surgery. The presence of a metastatic ganglion is an important and decisive factor in the choice of adjuvant or neoadjuvant management of cancers, especially for cervical cancer.

Laparoscopic Sacral Colpopexy: The "6-Points" Technique.

STUDY OBJECTIVE: To illustrate laparoscopic sacral colpopexy for pelvic organ prolapse, a new method using a simplified mesh fixation technique, with only 6 fixing points. DESIGN: Step-by-step explanation of the surgery using video (educative video). The video was approved by the local institutional review board. SETTING: University Hospital of Strasbourg, France (Canadian Task Force Classification III). PATIENTS: Women with multicompartment prolapse. INTERVENTION: We first dissected the promontorium and vertically incise the posterior parietal peritoneum on the right pelvic sidewall up the pouch of Douglas. We then dissect the rectovaginal septum up to the anal cap, laterally exposing the puborectalis muscle on each side. Middle rectal vessels can be coagulated and cut without increasing the risk of digestive disorders (especially constipation), but it is preferable to conserve them if the space is sufficient for suture. Then, we dissect the vesicovaginal space and realized the subtotal hysterectomy. Finally, we realized the fastening of the anterior and posterior meshes. The particularity is that we performed only 6 points for fixing the meshes: 1 on the puborectalis muscle on each side without tension (to reduce the risk of mesh contracture, dyspareunia, and chronic pelvic pain), 1 for the fixing of the anterior mesh on the anterior vaginal wall at the level of the bladder neck, and 1 on each side of the cervix for the reconstitution of the pericervical ring gathering together the anterior mesh, the pubocervical fascia, and the insertion of the uterosacral ligament at the level of the cervix and the posterior mesh. The sixth stitch fastened 1 of 2 meshes to the anterior paravertebral ligament at the level of the sacral promontory. We finished with the peritonization. MAIN RESULTS: The duration of surgery lasts approximately 120 minutes in well-experienced hands. Based on our experience the 6-point technique was relatively simple (few laparoscopic stiches) with few operative difficulties and was also associated with a low rate of reintervention. CONCLUSION: Surgical management of middle compartment prolapse could be performed quickly and efficiently under laparoscopy with the "6-points" technique.