ROCK LAKE – GYNECOLOGY SCIENTIFIC PAPERS & VIDEOS
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Cesarean Scar Ectopic Pregnancy – Laparoscopic Bilateral Uterine Artery Ligation With G. Sac Excision and Scar Revision (A Case Report)
Mahalakshmi Thayumana Sundaram1, Urmila Soman2
1Former Fellow, Dr Urmila’s Laparoscopic training center, Kochi, Kerala, India. 2Dr Urmila’s Laparoscopic training center, Kochi, Kerala, India
Video / Gynecology
Objectives: Management of laparoscopic scar pregnancy excision after bilateral uterine artery clipping and primary repair of uterine defect.
Methods and Procedures: Cesarean Scar Pregnancy (CSP) is implantation of blastocyst into the myometrial defect of previous cesarean incision. It is a rare and potentially life threatening ectopic pregnancy with increasing prevalence due to increasing Cesarean section rates. All available treatment modalities are associated with high risk of massive haemorrhage and need for hysterectomy.
31-years G5P2A2, with previous 2 cesarean deliveries and 2 surgical abortions at 9 weeks gestation was referred to our tertiary care hospital with incidental ultrasound diagnosis of CSP.
- 4 ports placed – One 10 mm, three 5 mm ports
- Bilateral uterine artery clipping – hemo-lock 5 mm laparoscopic clip applicator.
- Intramyometrial injection of 50 ml of diluted vasopressin (0.1 units/ml)
- Dissection of uterovesical fold and bladder pushed down.
- Unruptured ectopic gestational sac removed en masse
- Rent closed in 2 layers with absorbable 180 barb sutures. Trans- vaginally introduced Hegar’s dilator as guide for identifying the margins and delineating anterior and posterior walls of uterine cavity.
Results: The total operating time was 75 minutes with an estimated blood loss of around 200 ml. The patient was discharged on first POD
Conclusion: Primary laparoscopic management of cesarean scar pregnancy not only offers low complication rates but also allows for repair and revision of Cesarean scar defect in the same sitting. Bilateral uterine artery clipping offers better hemostasis and decreases the need for emergent hysterectomy.
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Interstitial Ectopic Pregnancy Management and Pregnancy Outcomes
Annalese Williams1,2, Renae Shibata1,2, Uchenna Acholonu1,2, Anjali Patel1,2
1Long Island Jewish Medical Center, New Hyde Park, NY, USA. 2North Shore University Hospital, Manhasset, NY, USA
Scientific Paper / Gynecology
Objective: Evaluate the success of medical versus surgical management of patients with interstitial ectopic pregnancies, evaluate possible surgical complications of a wedge resection, and evaluate outcomes of future pregnancies.
Methods & Procedures: Retrospective study cohort study of pregnancies with a history of interstitial ectopic pregnancy from 2016 to 2022 at two large tertiary hospitals in the New York Long Island area. Basic demographics, details on medical or surgical treatment, and any available pregnancy outcomes were collected.
Results: Thirty-nine cases of interstitial pregnancy were identified. Ten patients (25.6%) were initially treated conservatively with intramuscular methotrexate with seven of these patients (70%) requiring surgical intervention after increasing or plateau serum human chorionic gonadotrophin. Surgical intervention of cornual wedge resection was performed on 37 patients (75.4%) and included thirty-five laparoscopic (94.5%) and two laparotomies (5.5%). Fifteen patients had confirmed pregnancies following treatment of interstitial ectopic pregnancy. There was one subsequent fallopian tube ectopic pregnancy, two fetal demises, and eleven live births. Of the live births, eight of these deliveries were term (72.7%) and three were preterm deliveries (27.3%). There were eight cesarean deliveries (72.7%) and three vaginal deliveries (27.3%). There were no cases of abnormal placentation. There were no cases of uterine rupture.
Conclusion: Medical treatment of interstitial ectopic pregnancies was largely unsuccessful. As expected, cornual resection via laparotomy was associated with higher estimated blood loss. Following successful treatment, future pregnancies are possible with both cesarean and vaginal mode of delivery.
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Tips and Tricks for Fertility Sparing Adnexal Surgery
Adriana N Vest1, Papri Sarkar2, Emad Mikhail2
1University of South Florida, Tamp, FL, USA. 2University of South Florida, Tampa, FL, USA
Video / Gynecology
Objective: Present three different surgical cases with adnexal pathology, while considering the pros and cons for fertility sparing surgery, and demonstrating tips and tricks for optimizing post-surgical fertility.
Methods: We present three different cases of adnexal pathology and their surgical intervention. The first case includes a nulliparous female with advanced endometriosis and an endometrioma. Complete excision of the endometrioma is demonstrated, as excision is associated with higher pregnancy rates and lower recurrence rates than fenestration. Our second case demonstrates tuboplasty in a patient with tubal pathology consistent with serosal adhesions. Blunt and sharp dissection are utilized to separate the tube from the ovarian fossa. After dissection, chromopertubation is used to confirm patency of the tube. The last case demonstrates management of adnexal torsion. The ovary is detorsed using blunt instruments and the ovary is preserved, regardless of suspicion for necrosis. The cyst is identified and cystectomy is performed in order to remove the nidus of torsion. In all three cases, we demonstrate a judicious use of energy around the ovary to limit damage to the viable ovarian cortex and maximize post-surgical ovarian reserve.
Conclusion: Fertility sparing adnexal surgery is feasible and effective. Judicious utilization of energy is recommended. Basic skills to maintain ovarian reserve are considered essential for any gynecologic surgeon, and can maximize post-surgical fertility in all patients.
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Ovarian Preservation in Adolescent With Dermoid Cyst Adherent to the Hilum
Manuel A Merida
Hurley Medical Center, Flint, MI, USA
Video / Gynecology
BACKGROUND: Dermoid cyst is one of the most common ovarian lesions in premenopausal women; ovarian preservation should be attempted when laparoscopic cystectomy is offered to maintain fertility and hormonal homeostasis. Hilum preservation should be accomplished to avoid ischemic injury of ovarian tissue.
CASE: A 17-year-old G0 presented to the emergency room complaining of chronic pelvic pain of progressive severity with new onset of associated lower back pain, nausea, and vomiting. Abdominal and pelvic examinations were performed and were positive for mild to moderate hypogastric tenderness. Transvaginal ultrasound was performed resulting in an 8 cm heterogenous, hyperechoic mass in the right ovary with patent blood flow in both ovaries; findings were consistent with a dermoid cyst, which was confirmed after an abdominopelvic CT scan. Management options were discussed, and the patient expressed the desire for ovarian preservation, after reviewing the risk and benefits she consented to Laparoscopic right ovarian cystectomy with possible oophorectomy, and she was taken to the OR and right ovarian cystectomy was performed without complications.
CONCLUSION: Oophorectomy in premenopausal women should be left as last resort, and cystectomy should be attempted even when ovarian hilum disruption is encountered secondary to dermoid cyst contents or wall; this would offer the patient better outcomes in fertility and hormonal homeostasis preservation. Hilar preservation techniques should be explored and developed.
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Neosalpingostomy for Surgical Management of a Patient with Unilateral Congenital Hydrosalpinx
Yasmin A Korayem1, Mustafa I Abuzeid2,3
1Temple University Hospital, Philadelphia, PA, USA. 2Hurley Medical Center- Michigan State University/ College of Human Medicine, Flint, Michigan, USA. 3IVF Michigan, Rochester Hills, Michigan, USA
Video / Gynecology
Objective: To present the successful surgical management of unilateral congenital hydrosalpinx in an infertile patient
Methods & Procedures: We present a case of a 27 year old female with a history of PCOS presenting with 2 years of primary infertility despite successful ovulation induction with Clomiphene Citrate. Hysterosalpingogram suggested a left hydrosalpinx which could have contributed to failure to conceive. Lack of history of pelvic inflammatory disease, family history or clinical manifestations of endometriosis or history of abdominal surgery suggested that the hydrosalpinx was most likely of congenital etiology. Left congenital hydrosalpinx was confirmed laparoscopically. Unilateral distal neosalpingostomy of the congenital hydrosalpinx was then performed, thus preserving the left fallopian tube. Patient had 6 months of postoperative follow up.
Results: The patient conceived with the first cycle of ovulation induction, however pregnancy was terminated when found to be a partial molar pregnancy. Patient is currently attempting conception again.
Conclusion: Elimination of the effects of a unilateral hydrosalpinx after successful distal neosalpingostomy in patients with congenital hydrosalpinx may improve the pregnancy rates during ovulation induction or natural conception. Neosalpingostomy, when patients are properly selected, may enhance chances of spontaneous conception every cycle, thus avoiding the need for In Vitro Fertilization in such patients.
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Financial Feasibility of Vaginal Natural Orifice Transluminal Endoscopic Surgery Hysterectomy in Comparison to Total Laparoscopic Hysterectomy
Cemil Kilic1, Tayseer Ishag2, Truong Nguyen2
1The Istanbul Chamber of Commerce, Istanbul, Istanbul, Turkey. 2University of Texas Medical Branch, Galveston, Texas, USA
Scientific Paper / Gynecology
Objectives: Minimal invasive surgeries are associated with several advantages but also high costs. Lately, vaginal natural orifice transluminal endoscopic has been a new merging technique in gynecology and gaining more popularity. This study evaluates financial feasibility of outpatient vaginal natural orifice transluminal endoscopic hysterectomy for benign uterine pathology.
Methods & Procedures: Retrospective cohort study (Class II-2) of 13 patients who underwent vaginal natural orifice transluminal endoscopic hysterectomy for benign conditions by the same surgeon (T. Nguyen) at the University of Texas Medical Branch, Galveston, TX, USA, during September 2022-January 2023. The study only included cases considered appropriate for outpatient management and pure hysterectomy. Financial costs for patients discharged the same day were compared to 13 consecutive laparoscopic hysterectomy.
Results: Twenty-six cases (13 on each group outpatient) were analyzed. Payer types were not different among the groups (p > 0.05). Outpatient hysterectomy was associated with $ 6,762 average total direct cost in vaginal natural orifice transluminal endoscopic arm compared to $ 9,370 total laparoscopic hysterectomy. Average direct contribution margin was $ 6,611 in vaginal natural orifice transluminal endoscopic arm compared to $ 7,725 in total laparoscopic hysterectomy arm.
Conclusion: Financial analysis has revealed vaginal natural orifice transluminal endoscopic has less total direct costs compare to total laparoscopic hysterectomy. However, direct contribution Margin was higher in total laparoscopic hysterectomy arm.
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Impact of Race and Ethnicity on Perioperative Outcomes Among Women Undergoing Hysterectomy for Adenomyosis
Raanan Meyer1, Christina Maxey1, Kacey Hamilton1, Yosef Nasseri1, Moshe Barnajian1, Gabriel Levin2, Mireille D Truong1, Kelly N Wright1, Matthew T Siedhoff1
1Cedars Sinai Medica Center, Los Angeles, California, USA. 2McGill Medical Center, Montreal, Canada
Scientific Paper / Gynecology
Objective: To investigate racial and ethnic disparities among women undergoing hysterectomy performed for adenomyosis across the United States.
Methods & Procedures: A retrospective cohort study. We used the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2012-2020. Patients were identified through ICD-9/10 codes 617.0/N80.0 (endometriosis of uterus). We compared 30-day post-operative complications across the different racial and ethnic groups. Complications were classified into minor and major complications according to the Clavien-Dindo system.
Results: A total of 12,599 women underwent hysterectomy for adenomyosis during the study period: 8,822 (70.0%) White, 1,597 (12.7%) Hispanic, 1,378 (10.9%) Black or African American, 614 (4.9%) Asian, 97 (0.8%) Native Hawaiian or Pacific Islander and 91 (0.7%) American Indian of Alaska Native.
Post-operative complications occurred in 8.8% of cases (n=1,104), including major complications in 3.1% (n=385). After adjusting for confounders, Black race was independently associated with increased risk of major complications [adjusted odds ratio (aOR) 95% confidence interval (CI) 1.54 (1.16-2.04), p=0.003].
Laparotomy was performed in 13.7% (n=1,725) of cases. Compared with White race, the aOR for undergoing laparoscopy was 0.58 (95% CI 0.50-0.67) for Hispanic, 0.56 (95% CI 0.48-0.65) for Black or African American, 0.33 (95%CI 0.27-0.40) for Asian and 0.26 (95%CI 0.17-0.41) for Native Hawaiian or Pacific Islander race.
Conclusion: Among women undergoing hysterectomy for adenomyosis, Black or African American race was associated with an increased risk of major post-operative complications. Compared with White race, Hispanic, Black or African American, Asian and Native Hawaiian or Pacific Islander races were less likely to undergo minimally invasive surgery.
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Hysteroscopic Bridge Division Technique with Scissors for Management of False Passage
Manuel A Merida
Hurley Medical Center, Flint, MI, USA
Video / Gynecology
OBJECTIVE: Hysteroscopy represents the gold standard for the diagnosis and treatment of intracavitary uterine pathology, it is rarely associated with complications but 50% of them are associated with uterine cavity entry. The false passage occurs when the dilator enters the cervical muscle fibers, and it is correlated with early procedure termination or abortion. The objective is to educate about this pathology and to describe the different management techniques.
METHODS: This is a review of the literature on diagnosis and management of false passage, and a video presentation of an innovative technique for hysteroscopic intracervical bridge division.
RESULTS: False passage was diagnosed during operative hysteroscopy, using the hysteroscopic scissors the intracervical bridge was successfully divided, uterine cavity access was achieved and hysteroscopic polypectomy was completed.
CONCLUSION: False passage can occur during cervical dilation due to several factors. Early procedure termination might happen due to high fluid deficit and concerns of uterine perforation. Prevention and management of this pathology should be approached in a stepwise manner. Multiple techniques have been explored for management, hysteroscopic division of cervical bridge with scissors represents an easy and readily available technique to decrease the early hysteroscopic termination and abortion rate.
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Fibroid-Induced Compressive Neuropathy on Lumbar Plexus and Obturator Nerve
Pooja Vyas, Sun Woo Kim, Kari Plewniak
Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA
Video / Gynecology
Objective: Uterine fibroids are the most common benign gynecologic tumors in reproductive-aged women but vary in presentation from incidental findings to bulk symptoms and mass effect. We present a video review of a 32-year-old female with acute onset lower extremity pain and difficulty ambulating, found to have a large uterine fibroid causing compressive neuropathy and motor dysfunction requiring gynecologic surgical management. This video review demonstrates the need for urgent laparoscopic myomectomy.
Methods/Procedures: This is a surgical video review from a large urban academic institution of a patient who underwent a laparoscopic myomectomy. Four laparoscopic ports were used including three 5mm ports and one 30mm port.
Results: This 32 year-old who presented with lower extremity neuropathy and motor dysfunction was found to have a large posterior uterine fibroid causing lumbar plexus and obturator nerve compression. She underwent an uncomplicated laparoscopic myomectomy and had resolution in her motor dysfunction and significant improvement in her neuropathy. She did well postoperatively and was discharged home. This rare case demonstrates the need to have a high suspicion for uterine fibroids causing compressive neuropathy from mass effect requiring urgent evaluation and surgical intervention to prevent long-term sequelae.
Conclusions: Large pelvic masses causing compressive mass effect should be considered on the differential diagnosis for the etiology of non-gynecologic symptoms such as neuropathy, requiring urgent gynecologic evaluation and possible surgical management that can be performed with minimally invasive technique.
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Uterine Artery Blockage at Cervical Level in Laparoscopic Myomectomy
Pengfei Wang
BronxCare Health System, Bronx, NY, USA
Video / Gynecology
OBJECTIVE: To Introduce a new technique to temporarily block bilateral uterine arteries in laparoscopic myomectomy, in order to decrease blood loss.
METHODS & PROCEDURES: Patient was taken supine lithotomy position and a uterine manipulator was placed. A 12 mm trocar was placed in midline and 2 cm above suprapubic symphysis. Laparoscopic dissection was performed above the uterine manipulator ring, towards the ipsilateral round ligament. With the dissection in layers and millimeter to millimeter, the uterine artery was exposed. A similar procedure was performed on the other side. Laparoscopic bull dogs were used to block the uterine arteries. Laparoscopic myomectomy was then conducted following routine fashion. Finally, the suprapubic symphysis incision was extended to about 2 cm. Fibroid specimen was removed from this incision by containing morcellation.
RESULTS: The surgery was completed in 3 hours, with EBL 100cc, without intraoperative or postoperative complications. The patient was discharged on POD#1.
CONCLUSION: Compared to uterine artery blockage at pelvic side wall, the blockage of uterine artery at cervical level is easy to perform with high success rate.
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The Role of Hysteroscopic Myomectomy in an Infertile Woman with Multiple Submucosal Myomas
Macy Hudson, Manuel Merida
Hurley Medical Center, Flint, MI, USA
Video / Gynecology
OBJECTIVE: Uterine myomas affect fertility and pregnancy outcomes through mechanical distortion of the endometrial cavity, impairment of vascularization, and inflammation. They are associated with unexplained infertility, recurrent early pregnancy loss, along other negative outcomes. Although currently not recommended, there is fair evidence to support that hysteroscopic removal of type 0,1, and 2 myomas may or may not improve fertility.
METHODS: This is a review of the literature on the effect of hysteroscopic myomectomy on unassisted fertility and a video presentation of a case that exposes the importance of submucosal fibroids removal and its effect on fertility.
RESULTS: On a patient with 3 years history of unexplained fertility, multiple small submucosal myomas were diagnosed during hysteroscopy, and myomectomy was performed. The patient was sent home with an intrauterine Foley catheter for 1 week and a 6-week course of Estrace and Provera to avoid scar tissue formation and to aid with the healing of the endometrial lining. The patient attempted conception the following cycle and conceived. She had a normal spontaneous vaginal delivery at 36 weeks.
CONCLUSION: Multiple observational studies have shown the positive effect of hysteroscopic myomectomy on unassisted fertility and reproductive outcomes, however, remains inconclusive due to the current insufficient evidence-based data. This case illustrates that hysteroscopic myomectomy of multiple small submucosal myomas represents a safe and effective method for the preservation of functional endometrial surface to improve unassisted fertility and pregnancy outcomes.
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Robotic Management of Trocar Injuries
Natalie M Clark, Elizabeth Farabee, Sarah Todd, Daniel S Metzinger
University of Louisville, Louisville, KY, USA
Video / Gynecology
Objective: The goal of this surgical video is to discuss and demonstrate robotic management of trocar injuries.
Methods & Procedures: Abdominal entry was performed at Palmer’s point through an optical 5 mm trocar. Upon entry, distinct layers of the abdominal wall were difficult to visualize resulting in increased depth of trocar insertion. Following successful re-entry at Palmer’s point, additional trocars were then placed in the bilateral lower abdominal quadrants. The robot was docked facing the upper abdomen, and a survey of the omentum and surrounding vasculature was performed. The patient was placed in right lateral tilt for improved visualization of the great vessels. The bowel was gently pulled aside, and the course of the errant trocar placement was traced into the retroperitoneal space. This area was explored using careful blunt and sharp dissection. No obvious vascular injury was identified. The decision was then made to perform a systematic assessment of the small bowel to ensure no visceral injury had occurred during trocar entry, which was negative.
Results: The patient depicted within this video did well post-operatively and returned to the office for her two-week follow-up visit without complaints.
Conclusions: Traditionally, evaluation of trocar injuries has been performed via laparotomy. However, in the clinically stable patient without catastrophic injury, it is worthwhile to pursue minimally invasive assessment instead of defaulting to open abdominal incision.
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Enhanced Recovery After Surgery (ERAS) Practices in Minimally Invasive Gynecologic Surgery: A National Survey
Azra Shivji1, Elizabeth Miazga2, Carmen McCaffrey3, Sari Kives3, Alysha Nensi3
1University of Toronto, Toronto, Ontario, Canada. 2Trillium Health Partners, University of Toronto, Toronto, Ontario, Canada. 3Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
Scientific Paper / Gynecology
Objective Enhanced Recovery After Surgery (ERAS) pathways are evidence-based practices that minimize perioperative physiologic stress, thereby reducing postoperative complications and recovery time. This study aimed to assess the Canadian application of and adherence to ERAS protocols during minimally invasive gynecologic surgery, and identify barriers to ERAS uptake.
Methods & Procedures A self-administered cross-sectional survey was distributed to Obstetrics and Gynecology residents, fellows, and attendings through three national listservs from February 2021 to January 2022. The survey assessed 14 perioperative components per the American Association of Gynecologic Laparoscopists ERAS consensus guidelines.
Results 158 responses were analyzed of which 77% were attendings. 42% work within an established ERAS protocol. While 89% engage in preoperative anemia optimization, only 43% target the recommended hemoglobin >120g/L; notably, there was no significant difference in adherence rate with or without an ERAS program. While the majority counselled on hyperglycemia and sleep apnea, a smaller proportion (16-39%) discussed obesity, smoking cessation, and alcohol reduction. There was poor adherence to preoperative carbohydrate-loading (16%); however, this was significantly higher within ERAS programs (p< 0.001). Postoperatively, there was high adherence around multimodal analgesia, diet advancement (99%), and early ambulation (89%). Most respondents felt that ERAS pathways were safe (98%), and improved patient outcomes (82%).
Conclusion While the implementation of formal ERAS pathways differs between provinces and hospital sites, practitioners engage in various components of ERAS as per the consensus guidelines. Future and targeted research around low-adherence components would be beneficial in identifying and addressing barriers to optimize surgical care.
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★ Best Gynecology Video
Robotic-Assisted Laparoscopic Removal of Retained Suture Needle in an Obliterated Anterior and Posterior Cul de Sac
Bruce Lee, Sonia Koshy, Emery Salom
Center for Gynecologic Oncology, Miramar, FL, USA
Video / Gynecology
Objective: To review current literature on retained foreign objects and discuss surgical techniques for retrieval of a retained suture needle with an obliterated anterior and posterior cul de sac.
Methods & Procedure: Case report of a 43 year-old female with chronic right lower quadrant pain, endometriosis, and extensive surgical history was found to have a retained foreign object (suture needle) 5 months after she underwent a robotic-assisted laparoscopic left oophorectomy, extensive lysis of adhesions, retroperitoneal dissection, left ureterolysis, and uterosacral biopsy for a symptomatic complex left adnexal mass. Pathology was benign.
Results: Patient presented to the ED and CT abdomen and pelvis showed a 7 cm peritoneal inclusion cyst and a surgical foreign object in the left hemipelvis. A follow up abdominal x-ray showed a radiopaque structure suspicious for a retained suture needle. She underwent a robotic-assisted laparoscopic removal of a retained suture needle, resection of peritoneal inclusion cyst and lysis of adhesions by gynecologic oncology. The surgery was complex due to significant bowel adhesions and a obliterated anterior and posterior cul de sac.
Conclusion: Retained foreign objects during minimally invasive surgery is rare but can have life threatening complications. Expert surgical skills and appropriate preoperative imaging are necessary for successful retrieval.
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Office Hysteroscopy-Incorporation Into Daily Office Hours
Radha Syed
Staten Island University Hospital-Northwell Health, Staten Island, New York, USA. The Brooklyn Hospital Center, Brooklyn, New York, USA
Scientific Paper / Gynecology
Objective: To demonstrate the feasibility of doing a simple diagnostic procedure of Hysteroscopy with Endometrial sampling in a daily office setting during regular office hours.
Methods & Procedures: Retrospective collection of data from office procedures during last 5 years at 2 locations using a simple disposable hand held Hysteroscope-feasibility, time investment, required instrumentation, required personnel, the actual procedure, documentation of findings in EMR and follow up of pathological diagnosis and further management guidelines will be discussed. Complication rate will be discussed.
Results: The results of the retrospective analysis will show that it is completely feasible to perform office hysteroscopy with minimal personnel, minimal time and financial investment .The complication rate is low and mostly minor. The success rate of performing the procedure exceeded 95%.The diagnostic capability of office hysteroscope matched that of a larger scope with fluid management system in a hospital ambulatory setting. Histopathological correlation between Endometrial Biopsy and Endometrial curettage differed significantly in a few cases and the reasons for that will be discussed.
Conclusion: Office Hysteroscopy is a very important diagnostic tool which must be incorporated in every GYN office. A blind Endometrial biopsy leaves out many significant diagnostic possibilities which may impact the health of the patient population in an adverse way. This procedure reduces the number of people going into the OR unnecessarily.